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COLUMBIA    UNIVERSITY 

EDWARD  G.  JANEWAY 

MEMORIAL  LIBRARY 


Wztfi  t7ze  CcmxplimeThts  of 

THE  AUTHOR. 


BRIEF    ESSAYS    ON 
ORTHOPAEDIC    SURGERY 


INCLUDING  A  CONSIDERATION  OF  ITS  RELATION 
TO  GENERAL  SURGERY,  ITS  FUTURE  DEMANDS, 
AND  ITS  OPERATIVE  AS  WELL  AS  ITS  MECHAN- 
ICAL  ASPECTS,    WITH    REMARKS   ON    SPECIALISM 


BY 

NEWTON   M.   SHAFFER,   M.  D. 

Surgeon-in-Chief  to  the  New  York  Orthopaedic  Dispensary  and  Hospital ; 

Clinical  Professor  of  Orthopaedic  Surgery,  University  of  New  York 

City  (Medical  Department) ;  Consulting  Orthopaedic  Surgeon 

to  St.  Luke's  and  the  Presbyterian  Hospitals,  New  York  ; 

Consulting  Surgeon,  New  York  Infirmary  for  Women 

and  Children ;    Member  American   Orthopaedic 

Association,  New  York  Academy  of  Medicine, 

New  York  Neurological  Society,  etc. 


NEW  YORK 
D.  APPLETON  AND  COMPANY 

1898 


Copyright,  1898, 
By  D.  APPLETON  AND  COMPANY. 


PREFACE. 


At  the  request  of  a  few  friends,  who  have 
been  kind  enough  to  take  considerable  interest 
in  my  work,  these  essays,  which  have  appeared 
at  various  periods  during  the  past  fourteen 
years,  are  now  presented  in  their  present  form, 
and  they  are  submitted  to  the  medical  profes- 
sion and  the  public  with  the  hope  that  ortho- 
pedic surgery  may  be  benefited  by  their  pub- 
lication. __    __    _ 

N.  M.  S. 

28  East  Thirty-eighth  Street,  New  York, 
January  jo,  i8g8. 

iii 


CONTENTS. 


PAGE 

The  present  status  of  orthopaedic  surgery    .      i 

New  York  Medical  Journal,  January  26,  1884. 

What  is  orthopaedic  surgery?     .        .       .       .12 

Read  before  the  Orthopaedic  Section  of  the  Tenth  Inter- 
national Medical  Congress,  Berlin,  August  5,  1890.  Medical 
Record,  September  27,  1890. 

On  the  definition  and  scope  of  orthopaedic 
surgery 33 

New  York  Medical  Journal,  November  14,  1891. 

The  relation  of  orthopaedic  surgery  to  gen- 
eral SURGERY 46 

Boston  Medical  and  Surgical  Journal,  February  26,  1891. 

The  present   needs   and    future   demands    of 
orthopaedic  surgery 56 

New  York  Medical  Journal,  December  12,  1896. 

The  operative  side  of  orthopaedic  surgery     .    66 
Medical  Record,  December  18,  1897. 

is  orthopaedic  surgery  to  become  an  obsolete 
specialty? — With  remarks  on  specialism      .    76 

Medical  Record,  March  27,  1897. 

v 


BRIEF  ESSAYS  ON 
ORTHOPEDIC   SURGERY. 


THE    PRESENT    STATUS    OF 
ORTHOPAEDIC   SURGERY* 

Tracing  the  history  of  orthopaedic  surgery 
from  the  time  of  Andry  to  the  present  day,  we 
notice  that  its  more  important  progress  has 
taken  place  within  a  very  recent  period.  It 
will  be  further  noted  that  America  has  made 
by  far  the  most  important  contributions  to,  at 
least,  the  mechanical  element  in  orthopsedic  sur- 
gery, and  that  the  impetus  given  to  the  study  of 
diseased  joints  and  spines  by  American  sur- 
geons has  influenced  the  treatment  of  these  dis- 
eases and  deformities  throughout  the  entire 
world. 

*  Reprinted  from  the  New  York  Medical  Journal,  January  26, 

1884. 


2  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

Whether  it  was  Brodie  or  Harris  that  first 
used  or  pointed  out  the  value  of  traction  in  joint 
disease,  or  whether  the  possibility  of  successfully 
treating  Pott's  disease  by  the  modern  form  of 
apparatus  was  first  suggested  by  English  or 
American  surgeons,  matters  but  little  from  a 
practical  standpoint. 

It  will  probably  not  be  disputed  that  Dr.  H. 
G.  Davis,  formerly  of  New  York,  conferred  a 
.e^reat  benefit  upon  humanity  when  he  gave  his 
|  0^  perfected  apparatus  to  the  world,  embodying 
the  principles  of  traction  as  applied  to  joint  dis- 
ease ;  and,  since  his  day,  while  various  surgeons 
have  from  time  to  time  modified  and  changed 
Davis's  instruments,  the  Davis  principle  under- 
lies all  of  them.  His  plain  and  simple  directions 
as  to  the  mechanical  principles  involved  in  treat- 
ment are  followed,  more  or  less  in  detail,  by  al- 
most all  who  treat  diseased  spines  and  joints  to- 
day. 

Twenty-one  years  ago,  when  the  writer  be- 
gan the  study  of  orthopaedic  surgery,  there  was 
little  to  be  proud  of  in  its  status  in  the  city  of 
New  York.  At  that  time  a  certain  prominent 
surgeon,  in  speaking  to  the  writer,  not  only  dis- 
couraged the  adoption  of  orthopaedic  surgery 
as  a  specialty  but  predicted  that  any  one  adopt- 


PRESENT  STATUS  OF  ORTHOPEDIC  SURGERY.        3 

ing  it  would  fail  and  be  called  a  blacksmith  for 
his  pains. 

Forty  years  ago  orthopaedic  surgery  did  not 
include  joint  and  spinal  disease,  but  only  such 
deformities  as  clubfoot,  wryneck,  knock-knee, 
etc.  Strabismus  was  classed  as  an  orthopaedic 
condition  by  Bigelow  when  he  wrote  his  prize 
dissertation  in  1845 — about  ten  years  before 
Davis  gave  to  the  profession  his  treatment  of 
joint  and  spinal  diseases.  After  Davis's  time, 
those  making  any  pretense  to  the  treatment  of 
deformities  classed  joint  and  spinal  diseases  as 
orthopaedic ;  or,  at  least,  their  reputations  have 
been  due  to  successes  not  so  much  in  the  field 
of  operative  work  as  to  a  mechanical  aptitude 
in  the  treatment  of  the  diseases  and  deformities 
of  the  joints  and  spine.  It  is,  perhaps,  in  this 
latter  field  that  Bauer,  Sayre,  and  Taylor  ap- 
pear to  the  greatest  advantage,  and  the  teach- 
ings of  these  gentlemen,  all  more  or  less  in- 
spired by  Davis,  form  the  foundation  of  much 
of  the  orthopaedic  surgery  practiced  in  the 
United  States  to-day ;  for,  while  all  must  con- 
cede the  debt  owed  by  orthopaedic  surgery  to 
Dr.  W.  J.  Little,  of  London,  that  eminent  writer, 
the  father  of  orthopaedic  surgery  in  England, 
does  not  include  articular  disease  in  his  treat- 


4  ESSAYS   ON   ORTHOPAEDIC   SURGERY. 

ises,  and,  without  a  full  discussion  of  the  me- 
chanical and  secondarily  of  the  operative  treat- 
ment of  joint  disease,  no  treatise  on  orthopaedic 
surgery  can  now  be  called  complete. 

It  is  not  intended,  however,  to  make  this 
short  note  an  historical  review  of  orthopaedic 
surgery  ;  it  is  neither  profitable  nor  necessary 
to  raise  points  which  may  involve  questions  of 
priority.  It  is  rather  the  aim  of  the  writer  to 
give  a  short  sketch  of  what  orthopaedic  surgery 
is  to-day,  and  what  it  demands  from  those  who 
enter  upon  its  study  and  practice,  for  orthopae- 
dic surgery  may  now  be  ranked  among  the 
growing  and  necessary  specialties — as  a  more 
useful  one,  indeed,  than  some  which  make 
greater  pretensions. 

In  my  lectures  at  the  University  Medical  Col- 
lege and  at  the  New  York  Orthopaedic  Dis- 
pensary and  Hospital  I  have  ventured  to  define 
orthopaedic  surgery  as  follows :  "  That  depart- 
ment of  general  surgery  which  includes  the 
mechanical  and  operative  treatment  of  chronic 
and  progressive  deformities,  for  the  proper 
treatment  of  which  specially  devised  apparatus 
is  necessary." 

Whether,  therefore,  the  condition  be  one  of 
clubfoot,   joint    disease,    lateral    curvature,    or 


PRESENT  STATUS  OF  ORTHOPAEDIC  SURGERY.        5 

spinal  caries,  the  indications  are  to  be  studied, 
and  these  indications  are  to  be  met  from  a 
pathological,  anatomical,  surgical,  and  mechan- 
ical standpoint.  To  do  this  the  orthopaedic 
surgeon  must  be  fully  informed  upon  general 
medicine  and  surgery,  and  must  be  prepared  to 
prescribe  his  apparatus  precisely  as  a  general 
practitioner  prescribes  a  remedy  for  disease. 

In  order  to  satisfactorily  carry  out  the  sys- 
tem of  prescribing  apparatus  for  deformities, 
the  instrument-maker  should  be  placed  in  the 
same  category  as  the  pharmacist,  and  should 
supply  apparatus  for  deformities  only  upon  a 
prescription — i.  e.,  a  carefully  executed  diagram 
of  the  apparatus  needed.  But  how  is  an  edu- 
cated orthopaedic  surgeon  to  execute  this  plan? 
While  orthopaedic  surgery  has  advanced  to  the 
dignity  of  a  well-recognized  place  in  general 
surgery,  the  facilities  for  filling  a  mechanical 
prescription  are  in  some  respects  no  better  than 
they  were  fifty  years  ago.  As  a  rule,  the  instru- 
ment-maker who  now  fills  the  prescription  of 
the  orthopaedic  or  general  surgeon  is  not  un- 
willing to  treat  deformity  himself,  and  it  not 
infrequently  occurs  that  he  makes  suggestions 
to  the  patients  that  are  sent  to  him.  There  is, 
I  regret  to  say,  some  excuse  for  this,  for  it  has 


6  ESSAYS  ON   ORTHOPEDIC   SURGERY. 

sometimes  happened  that  the  instrument-maker 
has  a  better  idea  of  what  is  needed  than  the  sur- 
geon who  sent  the  patient  to  him,  for  the  reason 
that  orthopaedic  surgery  is  not,  as  a  rule,  taught 
in  our  medical  schools,  and  the  generally  lax 
way  in  which  chronic  deformities  are  referred 
to  leaves  the  newly  fledged  graduate  utterly 
unprepared  to  treat  them,  especially  in  a  me- 
chanical sense.  Nor  is  it  at  all  unusual  for  the 
instrument-maker  to  be  called  in  a  kind  of  a 
consultation  by  the  surgeon,  to  devise  some  sort 
of  apparatus  to  accomplish  an  ill-defined  end 
in  a  given  case  of  deformity  or  disease.  Still 
further,  there  are  scattered  throughout  the 
country  various  agents  of  the  prominent  in- 
strument-making firms — druggists,  for  example, 
who  prescribe  for  the  most  serious  cases  in 
orthopaedic  surgery  and  order  an  apparatus 
from  a  distance  about  which  they  know  little 
or  nothing,  except  that  gained  from  the  cata- 
logues. The  amount  of  deformity  —  not  to 
mention  incidental  suffering  and  expense  en- 
tailed by  this  system  of  ignorance  and  charla- 
tanry— can  not  be  estimated.  The  writer  knows 
that  in  a  certain  city  not  far  from  New  York  an 
instrument-maker  is  called  in  by  the  surgeons  of 
a  certain  hospital,  and  the  patient  is  practically 


PRESENT  STATUS  OF  ORTHOPAEDIC  SURGERY.       y 

turned  over  to  the  mechanic  after  a  diagnosis  is 
made,  as  if  there  were  something  degrading  and 
unprofessional  in  attending  in  detail  to  the  me- 
chanical department  of  orthopaedic  work. 

But  it  requires  education  and  a  long  system- 
atic training  to  make  a  competent  orthopaedic 
surgeon  ;  and  more :  it  requires  a  peculiar  adapt- 
ability to  successfully  prosecute  the  mechanical 
detail  in  any  case  of  orthopaedic  surgery,  even 
under  the  best  auspices.  The  orthopaedic  sur- 
geon should  be  able,  as  a  matter  of  education,  to 
make,  if  necessary,  the  apparatus  which  he 
needs.  He  should  at  least  know  how  to  make 
it;  he  should  know  more  than  his  workman 
about  the  various  grades  of  steel,  the  points 
where  strength  is  necessary,  where  lightness 
may  be  tolerated  without  sacrifice  to  strength, 
etc. ;  and,  indeed,  unless  one  is  willing  to  master 
such  details  and  to  become  a  mechanician  him- 
self, it  is  better  that  he  should  let  orthopaedic 
surgery  alone.  No  man  can  be  a  scientific  or- 
thopaedist, competent  to  give  to  his  patients  the 
skill  which  they  have  a  right  to  demand,  who 
does  not  become  responsible  for  everything  not 
directly  pertaining  to  the  manufacture  of  the  in- 
struments to  be  used.  The  day  can  not  be  very 
far  distant  when  the  truth  of  these  statements 


8  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

will  be  recognized ;  and,  while  a  more  com- 
prehensive course  of  instruction  in  orthopaedic 
surgery  will  be  demanded,  the  various  public 
institutions  will  provide  the  means  by  which  de- 
formities can  be  properly  cared  for. 

There  seems  to  the  writer  to  be  no  reason 
why  the  mechanical  element  of  treatment  should 
be  ignored  because  it  is  so  purely  manual ;  nor 
can  he  imagine  that  a  disease  or  a  deformity 
essentially  painless  in  its  nature,  though  insidi- 
ously progressive  in  character,  should  be  rele- 
gated to  an  uneducated  class  simply  because 
death  is  not  imminent.  The  pathological  con- 
ditions existing  in  many  cases  involving  de- 
formity are  very  serious,  and  should  not  be 
placed  in  the  hands  of  ignorant  or  designing 
men.  They  can  not  be  successfully  handled  by 
even  the  general  practitioner  unless  he  has  the 
time,  the  ability,  the  experience,  and  the  pa- 
tience to  follow  a  case  in  detail  for  perhaps 
two  or  three  years.  Success  such  as  ought  to 
characterize  orthopaedic  practice  comes  only 
through  hard  work,  patient  attention  to  detail, 
and  a  thorough  mastery  of  mechanical  surgery. 

These  matters  are,  I  think,  more  thoroughly 
appreciated  in  New  York  than  elsewhere  in  this 
country.    When  the  writer  was  appointed  ortho- 


PRESENT  STATUS  OF  ORTHOPEDIC  SURGERY.       g 

paedic  surgeon  to  St.  Luke's  Hospital,  eleven 
years  ago,  it  was  with  the  distinct  understand- 
ing that  these  principles  were  to  underlie  the 
orthopaedic  work,  and  the  success  of  the  move- 
ment there  is  greatly  due  to  this  provision. 

In  the  New  York  Orthopaedic  Dispensary 
and  Hospital  there  is,  in  direct  connection  with 
the  institution,  a  fully  equipped  mechanical 
room  in  which  four  or  five  men  are  constantly 
employed  making  apparatus  directly  under  the 
instructions  of  the  surgeons.  No  apparatus  is 
made  without  a  drawing,  and  careful  measure- 
ments accompanied  by  actual  outlines,  when 
necessary,  are  given  with  every  order.  No  re- 
pairs are  made  except  by  personal  instruction 
of  the  surgeons,  accompanied  by  drawings  if 
necessary.  The  consequence  is  that  patients  are 
there  treated  with  great  satisfaction,  and  the 
instrument-makers  have  there  become  skilled 
workmen,  some  of  whom  have  gone  to  the  aid 
of  orthopaedic  surgeons  in  other  cities.  It  is  a 
great  pleasure  to  note  in  this  connection  that  in 
another  city  steps  have  been  taken  to  introduce 
the  methods  of  the  New  York  Orthopaedic  Dis- 
pensary into  one  of  the  most  prominent  hospi- 
tals and  medical  schools  of  the  country.  The 
Orthopaedic  Dispensary  of  the  University  Hos- 


IO  ESSAYS  ON   ORTHOPEDIC   SURGERY. 

pital  in  Philadelphia  has,  in  connection  with  its 
service,  a  fully  equipped  shop,  supplied  with 
steam  power,  where  the  apparatus  used  is  made 
after  the  diagrams,  and  under  the  direction  of 
the  attending  surgeon.  This  change  can  not 
but  result  in  good,  for  reasons  that  must  be 
apparent  to  all.  It  relegates  the  instrument- 
maker  to  his  proper  sphere,  bringing  him 
wholly  under  control  of  the  surgeon,  upon 
whom  it  fixes  the  entire  responsibility  for  the 
conduct  of  his  cases.  No  delays  are  incurred 
either  in  making  new  apparatus  or  in  repairing 
old  ones,  and  the  patients  are  supplied  with  ap- 
paratus at  first  cost — an  important  item  when 
one  considers  the  enormous  prices  charged  by 
instrument-makers  for  their  apparatus.  The 
fact  is,  that  all  hospitals  should  be  similarly 
equipped  with  a  complete  orthopaedic  depart- 
ment. The  expense  is  not  great.  Dr.  A.  Sid- 
ney Roberts,  formerly  an  assistant  surgeon  to 
the  New  York  Orthopaedic  Dispensary  and 
Hospital,  and  through  whose  personal  exertions 
the  orthopaedic  shop  of  the  University  Hospital 
was  organized,  informs  me  that  the  entire  cost 
of  the  same  did  not  exceed  $2,000,  which  in- 
cludes a  building  erected  for  the  purpose,  and 
that  the  shop   is  now  nearly  self-sustaining — 


PRESENT  STATUS  OF  ORTHOPEDIC  SURGERY,     i  r 

the  actual  cost  of  production  only  being  charged 
to  those  patients  who  were  able  to  pay  it.* 
This  is  certainly  a  good  exhibit,  and  confirms 
our  experience  at  the  New  York  Orthopaedic 
Dispensary.  The  great  advantage  it  will  confer 
upon  the  institution,  the  surgeons,  and  the  pa- 
tients, leads  to  the  hope  that  other  colleges  and 
hospitals  throughout  the  country  may  be  led  to 
adopt  the  same  plan,  and  thus,  while  extending 
to  a  large  class  of  sufferers  all  the  benefits  of  a 
thorough,  systematic,  and  scientific  treatment, 
aid  in  placing  orthopaedic  surgery  in  its  proper 
status  before  the  profession  at  large. 


*  Since  the  resignation  and  death  of  Dr.  Roberts  this  work 
has  been  most  successfully  carried  on  by  Dr.  De  Forest  Willard 
and  Dr.  J.  K.  Young,  of  the  University  College  and  Hospital 
staff. 


WHAT   IS   ORTHOPAEDIC   SURGERY?* 

The  recent  action  of  the  Orthopaedic  Sec- 
tion of  the  New  York  Academy  of  Medicine  in 
appointing  a  committee  to  secure  for  ortho- 
paedic surgery  an  official  recognition  by  the 
Tenth  International  Medical  Congress  has  been 
successful.  Orthopaedic  surgery  is  placed,  by 
this  act,  upon  the  same  plane  with  the  other 
special  branches  of  medicine  and  surgery,  and 
an  important  duty  is  imposed  upon  those  who 
will  assemble  in  Berlin  to  participate  in  the 
proceedings  of  this  newly  created  section.  It 
would  seem,  from  the  many  replies  which  have 
been  received  by  the  committee  in  response  to 
the  circular  letter  which  was  sent  to  those  inter- 
ested in  orthopaedic  surgery,  that  there  exists  a 
very  general  desire  to  aid   this  important  de- 


*  Read  before  the  Orthopaedic  Section  of  the  Tenth  Interna- 
tional Medical  Congress,  Berlin,  August  5,  1890. 

Reprinted  from  the  Medical  Record,  September  27,  1890. 
12 


WHAT   IS   ORTHOPEDIC   SURGERY?  x* 

partment  of  surgery.  Over  one  hundred  re- 
plies have  been  received  from  English,  Conti- 
nental, and  American  surgeons.  With  a  few 
exceptions  the  replies  have  been  favorable  to 
the  views  and  wishes  of  the  committee. 

Of  those  who  have  expressed  doubts  as  to 
the  advisability  of  creating  a  special  section  of 
orthopaedic  surgery  at  the  congress,  some  have 
plainly  said  that  this  special  section  was  not 
necessary;  others  have  stated  that  in  certain 
localities  the  treatment  of  deformities  was  influ- 
enced by  a  class  of  men  who  were  not  regular- 
ly educated  surgeons  ;  while  others,  again,  see 
difficulty  in  drawing  the  line  between  general 
and  orthopaedic  surgery. 

These  facts  raise  some  important  questions 
which,  it  seems  to  the  writer,  should  be  dis- 
cussed by  the  members  of  the  orthopaedic  sec- 
tion at  its  first  meeting  in  Berlin;  and  the  re- 
marks that  I  have  the  honor  to  present  have 
been  suggested  by  the  evident  differences  of 
opinion  that  exist  regarding  the  status  of  ortho- 
paedic surgery.  And  the  writer  desires  to  state 
that  the  opinions  here  expressed  are  his  per- 
sonal views  only,  and  that  the  committee  ap- 
pointed by  the  Orthopaedic  Section  of  the  New 
York  Academy  of  Medicine  (of  which  the  writer 


H 


ESSAYS   ON   ORTHOPEDIC   SURGERY. 


has  the  honor  to  be  a  member)  is  in  no  way  re- 
sponsible for  them. 

It  seems  unnecessary  on  this  occasion  to 
consider  orthopaedic  surgery  from  a,  strictly 
speaking,  historical  standpoint.  A  few  histori- 
cal facts  may  be  mentioned,  however,  which 
bear  upon  the  rise  and  progress  of  the  treat- 
ment of  deformities. 

From  the  time  of  Andry  the  word  "  ortho- 
paedic "  has  been  identified  with  the  treatment 
of  deformities,  and  an  "  orthopaedist "  has  been 
one  who  treated  deformity.  But  it  was  not 
until  Stromeyer,  in  1830,  demonstrated  the  feasi- 
bility and  the  value  of  subcutaneous  tenotomy 
that  "  orthopaedics  "  obtained  its  first  firm  foot- 
hold in  the  profession.  Both  before  and  after 
Stromeyer's  time,  however,  mechanico-therapy 
was  the  fundamental  part  of  the  treatment  of 
deformities.  The  introduction  of  subcutaneous 
tenotomy  and  of  subcutaneous  myotomy  sup- 
plemented the  treatment  of  deformity  by  me- 
chanical means.  Subcutaneous  surgery  did  not 
dispense  with  the  mechanical  element  of  treat- 
ment ;  it  rather  emphasized  its  value  and  neces- 
sity. And  it  is  fitting  that  we  should  note  that 
the  first  great  advance  in  orthopaedic  surgery 
occurred   in  Germany,  under  the  influence  of 


WHAT    IS   ORTHOPAEDIC   SURGERY?  jr 

Stromeyer's  teachings,  and  that  his  methods 
soon  became  recognized  and  practiced  in  all 
parts  of  the  world. 

The  status  of  orthopaedic  surgery  in  1844, 
about  fourteen  years  after  Stromeyer's  methods 
were  introduced,  is  very  clearly  shown  by  the 
essay*  of  Dr.  Henry  J.  Bigelow  upon  ortho- 
paedic surgery.  In  this  work  Dr.  Bigelow 
quotes  largely  from  Stromeyer,  Guerin,  Bonnet, 
Velpeau,  Phillips,  Duval,  Dieffenbach,  and  Little. 
The  subjects  treated  by  Bigelow,  in  addition  to 
clubfoot,  lateral  curvature  of  the  spine,  torticol- 
lis, etc.,  include  both  stammering  and  strabis- 
mus. The  operation  for  the  last-named  condi- 
tion has  long  since  been  recognized  as  belonging 
to  the  special  department  of  ophthalmology, 
while  the  former  was  long  ago  abandoned.  It 
seems  clear,  however,  from  Bigelow's  essay,  that, 
at  the  date  he  wrote,  orthopaedic  surgery,  so  far 
as  operative  treatment  is  concerned,  was  synony- 
mous with  subcutaneous  tenotomy  and  subcu- 
taneous myotomy,  and  that  any  condition  re- 
quiring either  of  these  operations  was  to  be 
classed  under  orthopaedic  surgery. 

A  few  years  later,  or  about  1852,  an  Ameri- 

*  Manual  of  Orthopaedic  Surgery.     The  Boylston  Prize  Essay 
for  1844  ;  published  in  1845  in  Boston. 


l6  ESSAYS  ON   ORTHOPEDIC   SURGERY. 

can  surgeon,  Dr.  Henry  G.  Davis,  published  his 
essay,  in  which  he  advised  the  use  of  elastic 
traction  by  means  of  a  portative  apparatus  in 
the  treatment  of  hip-joint  disease.  He  also 
demonstrated  the  value  of  traction  apparatus 
for  overcoming-  the  deformities  occasioned  by 
chronic  articular  lesions.  The  treatment  of 
Pott's  disease  by  means  of  the  antero-posterior 
spinal  apparatus  was  also  demonstrated  by  Dr. 
Davis  and  Dr.  C.  F.  Taylor,  and  the  subject  of 
the  mechanical  treatment  of  chronic  joint  and 
spinal  disease  received  a  marked  degree  of  at- 
tention from  the  surgeons  of  the  United  States 
especially. 

In  this  field  Dr.  Lewis  A.  Sayre  and  Dr. 
Charles  Fayette  Taylor  became  very  conspicu- 
ous. They  amplified  Dr.  Davis's  apparatus,  and 
devised  many  forms  of  apparatus  for  the  treat- 
ment of  chronic  and  progressive  deformities, 
and  under  their  leadership  the  treatment  of 
chronic  joint  and  spinal  disease  became  a  dis- 
tinctive feature  of  the  American  School  of 
Orthopaedic  Surgery,  and  another  era  in  ortho- 
paedics, second  only  to  that  of  Stromeyer,  was 
inaugurated. 

Up  to  about  1870,  or  thereabouts,  it  would 
therefore  appear  that  two  important  factors  had 


WHAT   IS  ORTHOPEDIC   SURGERY?  17 

aided  in  placing  orthopaedic  surgery  upon  a 
satisfactory  basis :  First,  the  introduction  of 
subcutaneous  surgery  by  a  German  surgeon; 
and  secondly,  the  introduction  of  the  portative 
traction  method  of  treatment  of  chronic  joint 
disease  by  an  American  surgeon.  Of  the  for- 
mer it  may  be  said  that  subcutaneous  surgery 
is  rarely  used  in  the  treatment  of  chronic 
deformity  without  after-mechanical  treatment, 
which  after-mechanical  treatment  is  oftentimes 
more  important  and  essential  than  the  cutting 
operation,  and  special  skill  and  training  are 
often  required  to  apply  it  successfully.  Of  the 
latter  we  may  safely  say  that  it  is  not  until  the 
mechanical  treatment  has  proved  inefficient  that 
cutting  measures  are,  as  a  rule,  thought  of,  and 
that  when  cutting  measures  are  deemed  neces- 
sary the  after-treatment  calls  for  little  else  than 
simple  surgical  dressings,  which  do  not  demand 
a  special  orthopaedic  training  to  apply.  The  in- 
troduction of  the  traction  splint  in  the  treatment 
of  chronic  joint  disease,  as  well  as  the  introduc- 
tion of  the  antero-posterior  splint  for  Pott's  dis- 
ease, enlarged  the  field  of  practical  orthopaedics 
very  much.  "  Preventive  "  surgery,  the  highest 
aim  of  surgery,  became  an  important  factor  in 
the  treatment  of  this  class  of  chronic  deformi- 


1 8  ESSAYS  ON  ORTHOPEDIC  SURGERY. 

ties.  By  the  judicious  use  of  traction  apparatus, 
portative  or  otherwise,  deformity  can  be  pre- 
vented, and  in  many  cases  the  disease  producing 
the  deformity  can  be  arrested.  And  even  after 
the  deformity  of  chronic  articular  disease  has 
become  pronounced,  it  can,  in  many  cases,  be 
overcome  or  greatly  modified  without  any  cut- 
ting operation.  Indeed,  the  tendency  of  ortho- 
paedic surgery  has  always  been  toward  conserv- 
atism. Its  principal  victories  have  been  won  in 
this  field,  and  it  would  seem  to  be  a  great  error 
to  lose  sight  in  any  way  of  the  principal  factor 
which  has  contributed  so  largely  to  its  present 
position. 

Up  to  this  point,  or  about  1870,  it  will  be 
seen  that  orthopaedic  surgery  had  not  invaded 
the  field  of  general  surgery.  Availing  itself  of 
all  that  contributed  to  the  relief  of  deformity 
from  its  conservative  standpoint,  it  found  many 
difficult  problems  which  it  did  its  best  to  mas- 
ter. It  took  hold  of  and  cared  for  a  much  neg- 
lected class  of  humanity — a  class  that  had 
long  been  neglected  by  the  profession  at  large. 
Even  at  this  day  the  general  surgeon,  as  a  rule, 
cares  but  little  for  orthopaedic  work.  He  is 
fully  occupied  in  a  large  field  which  is  every 
day  becoming  more  exacting — while  the  ortho- 


WHAT   IS  ORTHOPEDIC   SURGERY?  jg 

psedic  surgeon  is  devoting  himself  to  a  depart- 
ment which  has  none  of  the  brilliancy  of  opera- 
tive surgery ;  which  requires  much  patient 
attention  to  mechanical  detail ;  which  demands 
special  facilities  for  altering  and  modifying  ap- 
paratus, and  a  special  training  and  education 
which  very  few  surgeons  have  received. 

It  is  not  many  years  ago,  however,  that  gen- 
eral surgery  began  to  invade  the  domain  of  or- 
thopaedic surgery.  This  is  especially  true  since 
the  Lister  method  has  become  so  universally 
accepted.  The  knife,  the  saw,  the  chisel,  and 
the  osteoclast  have  become  potent  factors  in 
the  reduction  of  obstinate  osseous  deformities. 
Knock-knee,  bowlegs,  old  and  obstinate  cases 
of  clubfoot,  and  other  conditions  are  relieved 
by  the  direct  surgical  method,  without  special 
after-treatment  except  simple  surgical  dressings. 
This  marks  another  era  in  the  treatment  of  de- 
formities, and  is  a  legitimate  advance  in  general 
surgery.  And  it  was  about  this  time  also  that 
joint  resections  began  to  attract  the  marked  at- 
tention of  surgeons  of  the  United  States. 

To  some  orthopaedic  surgeons  these  innova- 
tions of  general  surgery  have  proved  a  stum- 
bling-block. They  diverted  the  attention  from 
the  hard  and  rugged  paths  of  orthopaedic  work 


20  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

per  se  to  the  brilliant  work  of  the  general  sur- 
geon. I  know  myself  that  the  allurements  of 
the  operating  table  are  very  great,  for  about 
this  time  I  had  my  own  attack  of  "  surgical  fe- 
ver," which,  I  am  happy  to  say,  proved  a  self- 
limiting  fever  of  comparatively  short  duration. 
But  it  raised  the  questions  then,  as  it  raises 
them  now — Where  shall  the  line  be  drawn  ? 
What  is  orthopsedic  surgery  ?  Shall  orthopae- 
dic surgeons  be  general  surgeons  as  well,  and 
shall  general  surgeons  be  orthopaedists  ?  If 
these  questions  are  answered  in  the  affirmative, 
there  is  no  room  for  a  special  orthopaedic  sec- 
tion in  the  Berlin  Congress. 

Reference  has  already  been  made  to  Bige- 
low's  work,  published  in  1845.  If  we  compare 
it  with  Sayre's  work  on  Orthopaedic  Surgery 
and  Diseases  of  the  Joints,  published  in  1876,  or 
with  Bradford  and  Lovett's  work  on  Ortho- 
paedic Surgery,  published  in  1890,  we  will  see 
that  the  tendency  of  modern  orthopaedic  sur- 
gery is  to  invade  the  field  of  general  surgery. 
Bigelow's  work  teaches  subcutaneous  tenotomy 
and  myotomy  plus  special  mechanical  treat- 
ment, and  nothing  more.  It  does  not  mention 
diseases  of  the  joints  or  Pott's  disease  of  the 
spine.     It  deals  with  the  subject  of  the  mechan- 


WHAT    IS   ORTHOPAEDIC   SURGERY?  2I 

ical  treatment  of  chronic  deformity  in  a  meager 
way,  a  subject  which  is  full  of  brilliant  promise 
in  the  future.  It  suggests  a  field  which  has 
never  been  fully  developed,  and  which  rests 
with  orthopaedic  surgery  to  develop — viz.,  com- 
plete and  scientific  methods  of  mechanical  treat- 
ment, which,  when  fully  developed,  will  repre- 
sent as  much  of  real  value  to  the  human  race  as 
general  surgery  itself.  It  already  represents  a 
great  deal,  especially  in  the  mechanical  treat- 
ment of  chronic  joint  and  spinal  disease,  for 
since  orthopaedic  surgeons  have  done  so  much 
to  render  plain  the  early  diagnosis  of  joint  and 
spinal  diseases,  mechanico-therapy  can  prevent 
the  occurrence  of  deformity,  and  can  frequently 
arrest  the  disease  in  its  first  or  non-deforming 
stage.  And  still  more  :  when  the  articular  dis- 
ease has  advanced  and  pain  is  present,  or  when 
deformity  is  progressive  and  abscess  is  about  to 
form,  or  has  already  formed,  mechanico-thera- 
py, properly  understood  and  applied,  can  hold 
out  to  the  sufferer  more  than  the  operative  or 
general  surgeon.  In  the  field  of  chronic  articu- 
lar disease  alone  there  is  enough  to  do,  and 
enough  for  the  orthopsedic  surgeon  to  learn, 
without  invading  at  all  the  field  of  general  or 
operative  work. 


22  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

Let  us  see  the  position  Say  re  takes  in  1876. 
His  work,  already  mentioned,  covers,  generally 
speaking,  the  conditions  treated  by  Bigelow  in 
1844,  and  adds  to  the  list  "  diseases  of  the 
joints."  This  is  to  be  expected,  for  the  author's 
greatest  reputation  is  based  upon  his  experi- 
ence in  the  treatment  of  joint  and  spinal  dis- 
eases. He  is  especially  strong  in  his  description 
of  joint  and  spinal  conditions,  ample  attention 
being  given  to  diagnosis  and  prognosis.  He 
devotes  much  space  to  excision  of  the  joints. 
The  great  strength  of  his  work,  however,  lies  in 
its  orthopaedic  part,  or  in  the  description  of  de- 
formities and  their  mechanical  treatment.  The 
work  is  one  of  the  pioneers  in  an  important 
field,  Dr.  Louis  Bauer  having  covered  some- 
what the  same  ground  a  few  years  before.  The 
part  of  the  work  that  is  of  the  least  value  per  se 
is  the  part  which  treats  of  joint  excisions,  for 
the  reason  that  the  subject  is  well  considered 
and  amply  discussed  in  contemporary  surgical 
literature.  While  the  part  which  dwells  upon 
orthopsedic  surgery  is  novel,  interesting,  and,  in 
its  way,  classical. 

Bradford  and  Lovett,  in  1890,  group  all  de- 
formities under  one  head  of  "orthopsedic  sur- 
gery "  and  reject  the  qualifying  title  of  "  dis- 


WHAT    IS    ORTHOPEDIC    SURGERY? 


23 


eases  of  the  joints "  adopted  by  Sayre.  In 
addition  to  the  conditions  treated  by  Bigelow 
and  Sayre,  we  find  these  authors  include  sev- 
eral new  titles.  Among  them  are  the  "  cerebral 
paralyses  of  children,"  "  pseudo-hypertrophic 
paralysis,"  "  Dupuytren's  contraction,"  "  webbed 
fingers,"  and  "  functional  affections  of  the 
joints."  They  extend  the  surgical  aspect  of  the 
treatment  of  deformities  and  give  a  large  por- 
tion of  their  work  to  resection  of  the  joints, 
amputation  at  the  hip  joint,  laminectomy,  oste- 
otomy, osteoclasis,  etc.  It  seems  unnecessary 
to  call  attention  to  the  excellent  and  thorough 
way  in  which  the,  strictly  speaking,  orthopaedic 
part  of  the  work  is  executed.  It  is  rather  the 
object  of  the  writer  to  call  attention  to  the  un- 
necessary invasion  of  the  field  of  general  sur- 
gery, in  a  special  treatise  on  orthopaedic  sur- 
gery, when  the  purely  surgical  aspect  of  the 
conditions  named  is  amply  covered  in  the  cur- 
rent surgical  literature  of  the  day. 

None  of  the  writers  I  have  referred  to  de- 
fine orthopaedic  surgery  in  their  works,  and  the 
definitions  given  in  the  various  dictionaries  are 
familiar  to  us  all.  I  have  found  none  that  seems 
sufficiently  definite,  or  that  covers  the  ground 
from  the  standpoint  of  modern  orthopaedic  sur- 


24  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

gery.  Under  these  circumstances,  I  found  my- 
self, several  years  ago,  called  upon  to  define 
orthopaedic  surgery,  by  the  class  at  the  Uni- 
versity Medical  College,  and  I  then  ventured 
upon  the  following  definition  * :  "  Orthopaedic 
surgery  is  that  department  of  general  surgery 
which  includes  the  mechanical  and  operative 
treatment  of  chronic  and  progressive  deformi- 
ties, for  the  proper  treatment  of  which  spe- 
cially devised  apparatus  is  necessary."  I  would 
modify  this  definition  to-day  so  that  it  would 
read  as  follows :  "  Orthopaedic  surgery  is  that 
department  of  surgery  which  includes  the  pre- 
vention, the  mechanical  treatment,  and  the 
operative  treatment  of  chronic  or  progressive 
deformities,  for  the  proper  treatment  of  which 
special  forms  of  apparatus  or  special  mechanical 
dressings  are  necessary." 

No  one  doubts,  myself  least  of  all,  that  the 
orthopaedic  surgeon  should  be,  from  the  stand- 
point of  education,  a  surgeon  in  every  sense  of 
the  word  ;  that  he  should  be  a  well-educated 
medical  man,  with  ample  clinical  experience, 
before  he  enters  the  field  of  specialism.  In 
short,  it  seems  to  the  writer  that  the  orthopae- 

*  The  Present  Status  of  Orthopaedic  Surgery,  New  York  Medi- 
cal Journal,  January  26,  1884. 


WHAT    IS   ORTHOPEDIC   SURGERY?  25 

die  surgeon  should  take  a  step  in  advance  of  the 
general  surgeon,  and  that  his  education  should 
include  all  that  is  necessary  to  make  a  general 
surgeon,  before  his  study  of  mechanico-therapy 
is  commenced.  As  one  thus  equipped  enters 
the  field  of  orthopaedic  surgery  he  will,  if  he  is 
wise  enough  to  resist  the  temptation  to  become 
an  operative  surgeon,  find  many  valuable  mines 
to  be  explored,  and  much  to  be  learned  that  is 
as  yet  untouched  by  any  writer.  And  he  will 
find  ample  work  without  invading  the  field  of 
the  general  surgeon,  just  as  he  will  find  in  all 
parts  of  the  civilized  world  very  many  surgeons 
who  are  amply  qualified  to  perform  all  the  oper- 
ations of  surgery,  and  but  very  few  who  can 
intelligently  devise  and  apply  apparatus  in  the 
various  and  varying  conditions  of  chronic  de- 
formity. 

The  needs  of  orthopaedic  surgery  are  clearly 
shown  when  we  appreciate  how  thoroughly 
general  surgery  is  taught  in  all  the  universities 
and  colleges,  while  on  the  other  hand  me- 
chanico-therapy— a  very  wide  and  important 
field — is  too  apt  to  be  practically  ignored.  The 
result  is  that  the  work  that  should  fall  into  the 
hands  of  the  educated  surgeon  is  relegated  to 
the   commercial    instrument-maker.     We    have 


26  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

only  to  look  at  the  barber  pole  of  to-day  to 
recall  the  position  of  surgery  in  former  years, 
and  it  is  not  impossible  that  in  a  few  years  the 
opprobrium  that  attaches  to  mechanico-therapy 
will  become  a  thing  of  the  past,  and  that  we 
may  have  a  class  of  surgeons  interested  in 
orthopaedic  work  who  will  be  orthopaedic  sur- 
geons in  the  strictest  sense  of  the  word. 

From  the  standpoint  here  taken,  and  as  a 
matter  of  experience,  it  seems  to  the  writer  that 
the  invasion  of  the  field  of  general  surgery  by 
the  modern  orthopaedist  is  unnecessary  and  un- 
called for.  It  further  seems  to  the  writer  that 
it  can  only  bring  discredit  upon  a  new  and  im- 
portant field  of  work,  which  is  even  further 
removed  from  general  surgery  than  ophthal- 
mology or  laryngology.  This  invasion  will  di- 
rect the  attention  of  the  profession  to  the  weak 
point  in  the  armament  of  those  who  combine 
general  surgery  with  orthopaedic  work,  and  it 
will,  if  persisted  in  in  the  future,  break  down 
the  lines  between  it  and  general  surgery.  The 
remark  of  a  prominent  general  surgeon  to  the 
writer,  after  reading  the  latest  work  on  ortho- 
paedic surgery,  is  not,  perhaps,  so  much  out  of 
place.  He  said :  "  The  next  work  on  ortho- 
paedic surgery  will  likely  tell  us  all  about  frac- 


WHAT   IS  ORTHOPEDIC   SURGERY?  2J 

tures  and  dislocations."  The  fact  that  the  plan 
here  proposed  will  necessarily  limit  the  opera- 
tive work  of  the  orthopaedist  does  not  lessen 
either  the  importance  or  the  honor  of  the  work 
that  lies  before  him.  Operative  surgery  has  its 
own  place,  and  in  orthopaedic  work  that  place 
should  be  second  ;  and  operative  surgery  should 
be  used  by  orthopaedists  only  as  it  supplements 
mechanico-therapy.  Orthopaedic  surgery  is  as 
yet  in  its  infancy,  and  needs  men  with  strong 
heads  and  strong  hearts,  men  who  are  willing 
to  work  and  study  and  wait,  and  to  those  who 
do  this  there  will  be,  I  am  sure,  an  ample  reward. 
And  looking  at  the  subject  from  the  stand- 
point of  our  meeting  here  in  Berlin,  we  may 
learn  another  lesson.  The  only  possible  excuse 
for  the  foundation  of  a  special  section  of  ortho- 
paedic surgery  at  this  congress  is  the  rapid  rise 
and  development  of  mechanico-therapy,  espe- 
cially in  the  United  States.  There  would  be  no 
true  orthopaedic  surgery  to-day  if  mechanico- 
therapeutics  had  not  been  studied  long  and 
patiently  by  a  comparatively  small  body  of 
intelligent  surgeons.  And  if  the  committee 
who  addressed  their  petition  to  the  congress 
asking  recognition,  had  relied  upon  the  record 
of  orthopaedic  surgery  in  the  field  of  joint  re- 


28  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

sections,  amputation  at  the  hip  joint,  laminecto- 
my, osteotomy,  etc.,  I  fancy  that  the  committee 
would  have  been  referred,  and  rightfully  so,  to 
the  section  of  general  surgery. 

In  closing  my  remarks,  I  feel  that  I  ought  to 
state  that  the  conclusions  reached  in  this  paper 
are  based  upon  an  experience  of  nearly  thirty 
years  in  orthopaedic  work. 

In  1873  I  found  myself  in  charge  of  the  ortho- 
paedic service  of  St.  Luke's  Hospital,  with  no 
restrictions  as  to  the  operative  work  of  my  own 
department.  I  soon  found  that  the  purely  sur- 
gical aspect  of  the  work  was  very  attractive,  and 
that  my  interest  in  the  patients  under  my  care 
was  gauged  by  their  present  or  prospective 
operative  value — and  that  the  conservative  or 
orthopaedic  side  of  the  work  was  becoming  less 
interesting.  After  mature  reflection,  it  became 
apparent  that  the  operative  field  was  well  repre- 
sented in  the  eminent  surgical  staff  of  the  hospi- 
tal, and  that  it  was  clearly  my  duty  to  develop 
and  establish  the  principles  of  orthopaedic  sur- 
gery. After  reaching  this  conclusion  I  volun- 
tarily turned  over  to  my  colleagues  all  the 
purely  operative  work  which  required  no  ortho- 
paedic treatment  after  operation,  and  from  that 
time  up  to  the  day  of  my  resignation  I  operated 


WHAT   IS   ORTHOPAEDIC   SURGERY? 


29 


only  on  those  cases  which  would  necessarily  re- 
main under  my  care  after  operation.  Soon  after 
my  appointment  as  surgeon  in  charge  of  the 
New  York  Orthopaedic  Dispensary  and  Hospi- 
tal, an  attempt  was  made  to  combine  a  general 
surgical  staff  with  the  orthopaedic  work.  At 
first  it  seemed  to  be  just  what  was  needed,  and 
while  questions  of  jurisdiction  were  sometimes 
raised,  there  was  no  conflict  between  the  sur- 
gical and  orthopaedic  departments.  The  real 
difficulty  appeared  later,  when  it  was  found  that 
the  junior  medical  officers  seemed  to  lose  their 
interest  in  the  orthopaedic  work,  while  they  were 
very  active  in  the  purely  surgical  work.  The 
hospital  was  gradually  becoming  a  surgical  hos- 
pital rather  than  an  orthopaedic  one.  It  became 
apparent  to  the  trustees  after  a  while  that  the 
institution  was  drifting  away  from  its  avowed 
object.  After  a  time  the  surgical  staff  retired, 
and  since  that  time  the  institution  has  been  a 
strictly  speaking  orthopaedic  one. 

As  the  medical  officer  in  charge  of  the  New 
York  Orthopaedic  Dispensary  and  Hospital,  and 
having  absolute  control  of  its  surgical  policy,  I 
have  for  several  years — and  since  the  retirement 
of  the  actual  surgical  staff — -operated  only  on 
those  patients  who  required  special  orthopaedic 


30 


ESSAYS   ON   ORTHOPEDIC   SURGERY. 


care  after  operation.  All  other  cases  requiring 
surgical  operation  have  been  referred  to  some 
general  hospital ;  and  I  have  pursued  the  same 
course  in  my  private  practice — that  is,  I  have 
referred  all  patients  requiring  surgical  opera- 
tion, who  have  not  demanded  special  ortho- 
paedic care  after  operation,  to  a  general  surgeon. 
And  this,  I  believe,  is  the  proper  position  for 
the  orthopaedic  surgeon  to  take.  During  my 
service  at  St.  Luke's  Hospital  it  was  made 
apparent  very  soon  after  my  appointment  that 
the  resident  house  staff  took  little  or  no  in- 
terest in  the  orthopaedic  ward.  Their  interests, 
as  young  and  recently  graduated  men,  were  in 
general  surgery  and  general  medicine.  Aside 
from  this,  though  they  were  all  picked  men, 
very  few  of  them  seemed  to  possess  the  mechan- 
ical ability  which  is  an  essential  element  of  suc- 
cess in  orthopaedic  work.  After  a  few  years' 
effort  to  keep  the  house  staff  interested,  an  effort 
which  failed,  I  was  obliged  to  ask  the  hospital 
authorities  for  a  special  assistant. 

At  the  New  York  Orthopaedic  Dispensary 
and  Hospital  it  has  sometimes  been  difficult  to 
secure  the  attention  of  the  junior  staff  during  a 
period  long  enough  to  fit  them  for  future  ortho- 
paedic work.     At  the  end  of  six  months  or  a  year 


WHAT   IS  ORTHOPEDIC   SURGERY?  3! 

they  may  regard  themselves  as  fully  equipped 
orthopaedic  surgeons.  On  the  other  hand,  we 
have  had  able  men  as  assistants  whose  college 
and  competitive  examination  records  were 
high,  whose  mechanical  instincts  were  lacking. 
These  men  were  clearly  out  of  place  in  ortho- 
paedic work.  My  experience  proves  that  it  re- 
quires an  exceptional  man  to  succeed  in  or- 
thopaedic practice.  If  he  possesses  mechanical 
tastes  and  ability,  and  devotes  himself  to  ortho- 
paedic work  for  a  sufficient  period,  he  will  almost 
surely  succeed  in  reaching  a  high  place.  But  if 
he  attempts  at  the  same  time  to  do  the  work 
that  would  naturally  fall  to  the  general  surgeon, 
he  will,  sooner  or  later,  become  the  latter  in 
effect,  if  not  in  name.  And  if  he  does  not  pos- 
sess, in  a  high  degree,  an  educated  appreciation 
of  the  various  and  complex  mechanical  problems 
which  will  constantly  confront  him  in  daily  prac- 
tice, he  will  very  likely  turn  to  operative  meas- 
ures when  there  may  be  no  need  for  such  a  step. 
Nor  can  any  one  expect  to  equip  himself  as 
an  orthopaedic  surgeon  in  a  short  time.  After 
graduation,  and  a  term  of  service  as  an  interne 
in  a  hospital,  a  course  of  study  covering  at  least 
five  years  (including  a  wide  clinical  experience 
in  dispensary  and  hospital  work)  should  be  de- 


32 


ESSAYS  ON   ORTHOPAEDIC  SURGERY. 


manded  of  those  who  expect  to  become  orthopae- 
dic surgeons.  Orthopaedic  surgery  lies  wholly 
within  the  domain  of  "  chronic  "  surgery.  The 
junior  medical  officers  in  large  general  hospitals 
see  but  little  of  this  class  of  surgery.  On  the 
other  hand,  they  acquire  during  their  hospital 
residence  a  wide  experience  in  "  acute  "  surgery. 
No  one  can  acquire  a  safe  clinical  experience 
without  a  prolonged  study  of  many  cases ;  and 
in  the  chronic  joint  department  of  orthopaedic 
surgery  one  may  wait  several  years  before  see- 
ing the  end  of  one's  first  case. 

A  great  deal  will  be  expected  of  the  ortho- 
paedic surgery  of  the  future,  and  it  seems  to  the 
writer  that  the  sooner  the  followers  of  ortho- 
paedic surgery  realize  that  it  has  enough  in  itself 
to  sustain  its  well-earned  reputation  without  en- 
croaching upon  other  grounds,  the  better  it  will 
be  for  orthopaedy.  I  feel  a  natural  embarrass- 
ment in  thus  presenting  my  views,  but  I  also 
feel  that  it  is  a  duty,  which  the  present  occasion 
demands;  and  if  my  remarks  are  regarded  as 
embodying  the  conclusions  of  one  who  desires 
to  see  orthopaedic  surgery  occupy  the  high  place 
it  deserves,  I  shall  be  wholly  satisfied ;  and  if 
they  aid  at  all  in  solving  the  question  which 
heads  this  paper,  I  shall  be  content. 


ON   THE   DEFINITION   AND   THE 
SCOPE   OF   ORTHOPAEDIC   SURGERY* 

REPLY   TO  A    CRITICISM^ 

I  HAD  begun  to  think  that  my  remarks  on 
What  is  Orthopaedic  Surgery  ?  read  before  the 
International  Medical  Congress  held  in  Berlin, 
were  to  receive  the  most  formidable  and  crush- 
ing of  all  criticisms — viz.  :  the  silence  and 
neglect  of  my  colleagues.  A  whole  year  has 
passed  since  my  paper  was  read,  and  no  one  has 
been  kind  enough  to  take  any  notice  of  my 
attempt  to  define  modern  orthopsedic  surgery. 
I  was  therefore  much  pleased  to  know  that 
another  effort  would  be  made  to  define  ortho- 
paedic surgery  by  one  well  known  in  this  work, 

*  Delivered  before  the  American  Association  at  its  fifth  annual 
meeting. 

f  Vide  article  entitled  Orthopsedic  Surgery ;  its  Definition 
and  Scope,  New  York   Medical  Journal,   November  7,  1891. 

Reprinted  from  the  New  York  Medical  Journal  for  November 
14,  1891. 

33 


34  ESSAYS  ON   ORTHOPEDIC   SURGERY. 

whose  opinions  and  views  we  have  all  been 
glad  to  hear. 

While  I  can  not  but  feel  grateful  to  my 
friend  for  his  kind  attempt  to  clear  up  any  mis- 
interpretation of  my  position,  I  feel,  so  far  as 
our  German  friends  are  concerned,  that  his  ex- 
planation is  unnecessary.  Just  prior  to  the 
reading  of  my  essay  before  the  Orthopaedic 
Section  of  the  Berlin  Congress  I  distributed 
seventy-five  copies  of  the  essay  translated  into 
German  ;  and  I  noticed,  as  I  read,  that  many  of 
my  hearers  followed  me  line  by  line.  There 
was  doubtless  considerable  confusion  on  the 
first  day,  owing  largely  to  the  fact  that  I  read 
in  my  native  tongue.  But  whatever  doubt 
there  may  have  existed  was  set  at  rest  by  the 
appearance  of  my  essay,  kindly  translated  by 
my  friend  Dr.  F.  Beely,  of  Berlin,  in  the  Ber- 
liner klinische  Wochenschrift,*  soon  after  the 
adjournment  of  the  congress.  I  can  not  under- 
stand how  any  of  my  English-speaking  col- 
leagues, who  were  present  when  I  read  my 
essay,  misunderstood  my  plainly  stated  views. 

As  to  the  quotation  referring  to  my  personal 
responsibility   for   the   views   expressed,   I  feel 

*  Was  ist  orthopadische  Chirurgie  ?   Berliner  klinische  Wochen- 
schrift,  No.  43,  1890. 


THE   SCOPE   OF   ORTHOPEDIC    SURGERY. 


35 


that  I  ought  to  say  that  I  had  the  honor  of  in- 
augurating the  movement  which  resulted  in  the 
recognition  of  orthopsedic  surgery  by  the  Ber- 
lin Congress ;  and  that,  as  chairman  of  the  com- 
mittee, I  should  have  been  false  to  my  trust  if  I 
had  permitted  even  an  inference  that  the  com- 
mittee as  a  whole  was  in  any  way  responsible 
for  the  views  expressed. 

We  have  all  listened  with  pleasure  to  our 
friend's  remarks.  But  he  does  not,  I  think, 
make  it  clear  why  orthopaedic  surgeons  should 
undertake  to  do  the  work  that  the  general  sur- 
geon is  so  well  equipped  to  perform.  He  does 
not  make  it  clear  why  orthopaedic  surgeons 
should  not  confine  themselves  to,  strictly  speak- 
ing, orthopaedic  work — which  is  as  yet  in  its  in- 
fancy of  usefulness  to  humanity,  and  which  has 
before  it  a  career  of  great  brilliancy. 

I  think  we  are  all  agreed  that  specialties  in 
medicine  are  the  natural  outgrowth  of  a  true 
progress ;  and  that  no  specialty  ought  to  suc- 
ceed which  attempts  to  cover,  or  which  even 
invades,  the  well-defined  limits  of  general  medi- 
cine or  general  surgery.  In  short,  all  special- 
ties in  medicine  should  have  a  distinct  and 
valid  reason  for  their  existence.  If  we  stop  to 
ask   how   orthopaedic   surgery   became   a    spe- 


36  ESSAYS   ON   ORTHOPAEDIC   SURGERY. 

cialty,  we  can  readily  answer  that  it  was  due  to 
the  undeserved  neglect  of  mechanico-therapy 
by  the  entire  medical  profession.  A  few  ear- 
nest and  intelligent  surgeons  have  rescued  me- 
chanico-therapy from  its  unenviable  position, 
and  have  made  it  what  it  is  to-day.  They  did 
it,  not  by  devising  new  operative  procedures 
for  the  relief  of  deformity — the  general  surgeon 
did  that ;  but  by  investigating  and  studying  the 
mechanical  principles  involved  in  the  treatment 
of  deformity,  and  by  inventing  apparatus  to 
meet  the  required  therapeutical  ends.  Without 
the  work  of  these  men,  the  present  American 
Orthopaedic  Association  would  have  had  no  ex- 
istence, and  orthopaedic  surgery  as  a  distinct 
specialty  would  scarcely  be  recognized  to-day. 

It  is  universally  admitted,  I  think,  that  all 
specialists  in  medicine  should  be  thoroughly 
equipped  both  in  medicine  and  surgery,  and 
there  is  no  reason  why  one  thus  equipped 
should  not  practice  both  general  medicine  and 
general  surgery.  It  must,  however,  be  appar- 
ent that  the  so-called  specialist  who  does  this 
weakens  his  own  claim  to  specialism  and  apolo- 
gizes for  his  specialty.  This  will  be  true  so 
long  as  medicine  and  surgery,  generally  speak- 
ing, are  progressive  and  so  long  as  there  are 


THE   SCOPE   OF   ORTHOPEDIC   SURGERY. 


37 


unsolved  truths   awaiting    the    special   investi- 
gator and  the  special  student. 

This,  it  seems  to  me,  is  especially  true  of 
orthopaedic  surgery.  There  is  much  to  be  done, 
much  to  be  learned,  in  the  mechanical  treat- 
ment of  deformities,  while  the  surgical  treat- 
ment of  deformities  will  receive  ample  and 
well-prepared  attention  from  the  general  sur- 
geon. A  brilliant  future  awaits  those  who  will 
steadfastly  devote  themselves  to  the  develop- 
ment of  the  scarcely  taught  and  the  compara- 
tively unknown  branch  of  mechanico-therapy. 
There  are  unexplored  fields  in  sight  with  rich 
rewards  awaiting  the  patient  tiller ;  and  while 
there  is  so  much  to  learn,  so  much  to  be  devel- 
oped, and  so  much  to  be  made  available  for  the 
benefit  of  suffering  humanity  in  these  unex- 
plored fields  of  mechanico-therapy,  some  ortho- 
paedic surgeons  are  content  to  ignore  the 
benefit  they  could  bestow  upon  humanity  by 
perfecting  true  orthopaedic  surgery  and  are 
willing  to  follow  more  or  less  in  the  beaten 
paths  of  general  surgery.  And  we  will  all  ad- 
mit that  the  general  surgeon  is  fully  prepared 
to  perform  all  the  operations  for  the  relief  of 
certain  chronic  deformities  and  that  he  needs 
no  help  from  the  orthopaedic  surgeon  in  apply- 


38  ESSAYS  ON   ORTHOPAEDIC   SURGERY. 

ing  the  conventional  surgical  dressings  they 
require ;  but  we  also  know  that  the  early  train- 
ing of  the  general  surgeon  does  not  prepare 
him  to  apply  properly  devised  apparatus  in  the 
more  difficult  cases  of  chronic  or  progressive 
deformity.  It  should  be  the  aim  of  orthopaedic 
surgeons  to  excel  in  that  which  gives  ortho- 
paedic surgery  its  existence  and  makes  it,  prop- 
erly interpreted,  one  of  the  most  distinct  and 
necessary  of  all  the  special  branches  of  medi- 
cine. 

Orthopaedic  surgery  has  had  its  first  trials 
and  has  slowly  reached  a  point  from  which  it 
can  look  forward  to  ultimate  success.  Sooner 
or  later  it  will,  I  think,  reach  a  point  where 
its  followers  will  be  true  orthopaedic  sur- 
geons. 

In  the  present  status  of  orthopaedic  surgery 
the  invasion  of  the  field  of  the  general  surgeon 
by  the  orthopaedist  can  only  be  justified  on  the 
plea  of  expediency ;  but,  as  a  matter  of  princi- 
ple, it  can  never  be  just  or  wise  for  orthopaedic 
surgeons  to  leave  the  undeveloped  fields  of  true 
orthopaedic  science  for  the  well-trodden  but 
perhaps  more  attractive  paths  of  general  sur- 
gery. To  mingle  the  two  is  to  endanger  both, 
especially  the  orthopaedic  part.    There  are  very 


THE   SCOPE   OF   ORTHOPEDIC   SURGERY. 


39 


few  of   us  who   have   not   witnessed   examples 
which  prove  this  statement. 

We  may  go  anywhere  in  the  civilized  world 
and  we  shall  find  general  surgeons  who  have 
been  amply  educated  to  perform  all  the  opera- 
tions of  general  surgery.  The  medical  colleges 
and  universities  of  the  world  are  monuments  to 
the  brilliant  success  of  general  surgery.  On 
the  other  hand,  how  many  of  the  cities  of  the 
world  contain  men  who  have  received  a  thor- 
ough training  in  orthopaedic  work  and  meth- 
ods ?  A  liberal  training  in  our  colleges  and 
hospitals  does  not  make  an  orthopaedic  surgeon 
any  more  than  it  makes  an  ophthalmologist  or 
neurologist.  Years  of  post-graduate  study  and 
work  are  necessary  to  make  an  accomplished 
specialist  in  orthopaedic  surgery  ;  and  when  one 
has  mastered  the  rudiments  of  the  science — and 
the  best  of  us  have  only  done  this — he  will  even 
then  have  to  be  on  his  guard  or  he  will  be  di- 
verted from  his  plain  line  of  duty  by  the  attrac- 
tiveness and  brilliancy  of  operative  work.  The 
true  orthopaedic  surgeon  will  desire  to  extend 
the  benefits  of  a  developed  mechanico-therapy 
to  relieve  the  sufferings  and  the  deformities  of 
the  human  race  ;  and  he  will  find  his  time  fully 
taken  up  in  one  of  the  most  attractive  fields  of 


40 


ESSAYS   ON   ORTHOPEDIC    SURGERY. 


study  in  the  whole  range  of  medicine.  His  re- 
ward will  be  ample,  for  the  benefits  which  will 
accrue  to  humanity  from  a  perfected  ortho- 
paedic science  will  be  second  only  to  the  grand 
results  of  operative  surgery  itself ;  but  he  who 
would  strive  for  this  goal — of  the  greatest  good 
to  suffering  humanity — must  necessarily,  in  the 
present  state  of  orthopaedic  surgery,  work  in 
new  fields.  He  must  devote  all  his  energies  and 
time  to  his  work,  and  he  will  scarcely  have  time 
— even  if  he  has  the  inclination — to  compete  with 
the  general  surgeon  in  the  field  of  operative  work. 

The  pleasure  that  attends  the  practice  of  or- 
thopaedic surgery  needs  only  to  be  stated  to  be 
appreciated.  As  I  have  remarked  elsewhere, 
orthopaedic  surgery  is  an  exact  science.  The 
orthopaedic  surgeon  is  dealing  with  mathemati- 
cal and  mechanical  problems  all  the  time,  and 
the  application  of  the  principles  of  treatment  is 
limited  only  by  the  vulnerability  of  the  human 
tissues  and  his  therapy  is  regulated  by  his  own 
hands.  If  his  patience  equals  his  confidence, 
the  orthopaedic  surgeon  can  achieve  many  very 
brilliant  results. 

So  long  as  orthopaedic  surgeons  combine 
general  operative  surgery  with  their  orthopae- 
dic practice,  the  medical  profession  will  fail  to 


THE   SCOPE  OF   ORTHOPAEDIC   SURGERY.     41 

properly  recognize  their  position.  This  will  ac- 
crue to  the  advantage  of  an  uneducated  class  of 
instrument-makers,  whose  efforts  to  serve  the 
profession  are  laudable,  but  whose  failures  are 
only  to  be  expected.  So  long  as  this  unedu- 
cated class  are  relied  upon  by  the  profession, 
humanity  will  be  the  sufferer,  and  the  general 
surgeon  will  be  dissatisfied  with  his  manage- 
ment of  cases  of  chronic  deformity  requiring 
special  mechanical  treatment.  The  medical  pro- 
fession need  educated  orthopaedic  surgeons  to 
whom  they  can  refer  patients  with  chronic  de- 
formity requiring  special  mechanical  treatment 
with  confidence  ;  and  the  orthopaedic  surgeons, 
*  with  equal  confidence  and  with  a  merited  self- 
respect,  should  refer  their  operative  cases  not 
requiring  special  orthopsedic  care  after  opera- 
tion to  the  general  surgeon. 

By  and  by  a  sufficient  number  of  surgeons 
trained  in  orthopaedic  work  and  methods  will 
exist,  and  then  the  profession  at  large  will  rec- 
ognize their  position  and  claims.  Then  the  in- 
strument-maker will  be  relegated  to  the  posi- 
tion which  the  pharmacist  now  occupies — viz. : 
that  of  "  compounding  "  the  "  prescription  "  of 
the  surgeon. 

There  is  too  much  false  pride  among  some 


42  ESSAYS   ON   ORTHOPAEDIC   SURGERY. 

orthopaedic  surgeons — and  this  false  pride  inter- 
feres very  materially  with  the  advance  of  true 
orthopaedic  surgery.  Some  orthopaedic  sur- 
geons seem  to  want  to  be  recognized  as  opera- 
tive  surgeons.     They  dislike,   for   example,  to 

have  it  said  :  "  Oh,  yes,  Dr. is  good  enough 

at  applying  a  brace  for  deformity,  but  they  say 
he  is  too  timid  to  excise  a  joint."  The  conse- 
quence is  that  Dr. wants  to  prove  his  abil- 
ity to  perform  all  the  operations  of  surgery.  I 
have  heard  remarks  like  this  made  of  some  of 
our  best  orthopaedic  surgeons — I  know  it  has 
been  said  of  myself.  But  we  must  rise  above 
such  puerile  criticism.  The  fact  that  we  choose 
to  send  our,  strictly  speaking,  operative  cases# 
directly  to  some  general  hospital  or  to  some 
general  surgeon  places  the  orthopaedic  surgeon 
in  a  secure  position ;  for  the  difficult  cases 
which  he  retains  and  which  he  is  competent  to 
treat  are  better  cared  for  than  they  could  be  by 
the  general  surgeon — and  we  know  that  the 
general  surgeon  is  fully  equipped  to  care  for 
the,  strictly  speaking,  operative  cases.  If  we 
candidly  study  the  element  of  humanity  and 
progress  in  our  work,  it  would  seem  that  this 
would  be  the  best  for  those  whose  interests  are 
committed  to  our  care. 


THE   SCOPE   OF   ORTHOPAEDIC   SURGERY.     43 

But  I  must  not  be  misinterpreted.  The  ma- 
jor work  of  the  orthopaedic  surgeon  lies  in  the 
mechanical  field.  On  the  other  hand,  he  must 
be  prepared  and  equipped  to  operate  when  his 
work  demands  it,  and  he  must  keep  abreast  with 
current  medical  thought  and  practice.  He  is 
not  to  be  a  mechanic  alone.  But,  as  a  matter 
of  principle,  and  a  logical  sequence  of  his 
chosen  specialty,  the  orthopaedic  surgeon  should 
only  operate  upon  those  patients  with  chronic 
deformity  who  ought  necessarily  to  remain 
under  his  care  after  operation.  This  is  where, 
I  think,  the  operative  line  should  be  drawn,  for 
the  function  of  the  orthopaedic  surgeon  should 
be  to  fill  a  place  not  occupied  by  the  general 
surgeon.  This  position  is  one  which  all  ortho- 
paedic surgeons  can  occupy  with  credit  to  them- 
selves— and  if  it  is  maintained,  it  will  result 
greatly  to  the  credit  of  orthopaedic  surgery  and 
to  the  benefit  of  suffering  humanity. 

I  can  not  but  feel  flattered  in  thinking  that 
our  friend  has  adopted  my  definition  of  ortho- 
paedic surgery  in  every  respect  except  the  final 
and  qualifying  clause.  He  would  have  it  read 
as  follows  :  "  Orthopaedic  surgery  is  that  de- 
partment of  surgery  which  includes  the  pre- 
vention, the  mechanical  treatment,  and  the  op- 


44  ESSAYS  ON   ORTHOPEDIC   SURGERY. 

erative    treatment    of    chronic    or-  progressive 
deformities." 

Let  us  see  where  this  would  lead  us.  It 
would  make  the  orthopaedic  surgeon  a  general 
surgeon  in  effect.  He  would  be  called  upon  to 
trephine  for  cerebral  paralysis,  to  perform  lam- 
inectomy for  spinal  paralysis,  to  amputate  for 
incurable  deformity,  to  excise  diseased  joints 
which  do  not  require  mechanical  treatment,  and 
to  operate  for  spina  bifida,  harelip,  elephantia- 
sis arabica,  etc.,  and  in  cases  requiring  plastic 
surgery,  etc. 

I  respectfully  submit  that  these  operations 
belong  to  that  class  which  our  friend  calls  "  the 
operative  procedures  that  legitimately  belong 
to  the  general  surgeon,"  to  which,  he  says,  "  or- 
thopaedic surgery  lays  no  claim." 

The  above-mentioned  modification  of  my 
definition  would  lead  us  far  from  the  goal 
which  all  orthopaedic  surgeons  should  strive 
to  reach. 

On  the  other  hand,  it  would  appear  that  the 
definition  submitted  at  the  Berlin  Congress 
draws  a  very  distinct  line,  founded  on  the  real 
traditions  of  modern  orthopaedic  surgery.  It 
places  orthopaedic  surgery  in  a  clearly  defined 
position,  which  makes  it  incumbent  upon  its  fol- 


THE   SCOPE   OF   ORTHOPAEDIC   SURGERY.      45 

lowers  to  operate  in  those  conditions  only  which 
clearly  demand  special  orthopaedic  care. 

In  order  to  be  explicit,  I  again  submit  my 
definition  of  orthopaedic  surgery  as  read  before 
the  Berlin  Congress.  It  is  as  follows :  "  Ortho- 
paedic surgery  is  that  department  of  surgery 
which  includes  the  prevention,  the  mechanical 
treatment,  and  the  operative  treatment  of 
chronic  or  progressive  deformities,  for  the  proper 
treatment  of  which  special  forms  of  apparatus  or 
special  mechanical  dressings  are  necessary." 


THE  RELATION   OF  ORTHOPAEDIC 
SURGERY    TO    GENERAL    SURGERY* 

Gentlemen:  It  has  been  for  several  years 
the  special  function  of  the  New  York  Ortho- 
paedic Dispensary  and  Hospital  to  aid  in  the 
development  of  purely  orthopaedic  methods. 
Its  work  has  been  to  develop  and  improve  the 
much-neglected  branch  of  mechanico-therapy. 
It  has  devoted  much  time  and  effort  to  the  early 
recognition  of  the  deforming  diseases,  especially 
of  childhood,  and  it  has  aided  in  devising  meth- 
ods not  only  for  the  prevention  of  deformity, 
but  also  for  relieving  or  curing  it  after  it  has 
occurred.  While  the  general  surgeon  has  been 
occupied  in  bringing  operative  surgery  to  its 
present  very  high  standard  of  efficiency,  your 

*  An  address  delivered  before  the  Trustees  of  the  New  York 
Orthopaedic  Dispensary  and  Hospital,  upon  the  occasion  of  its 
twenty-third  annual  meeting. 

Reprinted  from  the  Boston  Medical  and  Surgical  Journal  of 
February  26,  1891. 
46 


THE   RELATION   TO   GENERAL   SURGERY. 


47 


institution  has  been  working-  in  a  field  of  almost 
equal  importance — though  far  less  brilliant  and 
far  less  attractive  to  the  rank  and  file  of  the 
medical  profession. 

The  operative  side  of  general  surgery  has 
always  been  well  taught  in  all  the  medical  col- 
leges and  universities.  On  the  other  hand,  there 
has  been  in  the  same  institutions  an  almost  gen- 
eral neglect  of  orthopaedic  surgery — a  depart- 
ment of  surgery  almost  as  important  as  opera- 
tive surgery  itself,  and  one  which  is  of  great 
value  to  the  human  race.  Your  institution  has 
been  content  to  work  in  those  lines  which  would 
aid  in  removing  the  unjust  opprobrium  that  at- 
taches to  mechanico-therapy,  and  in  demonstrat 
ing  the  usefulness  and  the  wide  range  of  prop- 
erly applied  mechanical  principles  of  treatment. 

In  short,  your  institution  has  been  steadily 
working  upon  conservative  lines — neither  ignor 
ing  the  great  strides  in  general  surgery,  nor  for- 
getting its  own  mission.  Its  efforts  have  been 
rewarded  in  more  ways  than  one.  The  steady 
increase  in  the  number  of  patients  which  have 
sought  your  services  was  mentioned  in  the  last 
annual  report ;  and  while  orthopaedic  institu- 
tions and  orthopaedic  departments  of  institu- 
tions   and    orthopaedic    clinics   at   the   colleges 


48  ESSAYS  ON   ORTHOPAEDIC   SURGERY. 

have  multiplied  in  New  York  city  and  else- 
where since  this  institution  was  organized  in 
1866,  it  still  remains  a  fact  that  a  large  percent- 
age of  the  patients  which  apply  to  your  institu- 
tion for  treatment  have  previously  had  no  ortho- 
paedic treatment  at  all ;  and  while  there  are  now 
quite  a  number  of  places  to  which  the  poor  crip- 
ple may  apply,  so  broad  and  so  generous  is  the 
philanthropy  of  New  York,  the  important  ortho- 
paedic institutions  of  our  city  are  overcrowded, 
and  some  of  them,  like  our  own,  are  asking  for 
more  room  and  increased  facilities.  • 

The  subject  of  mechanico-therapy  is  so  im- 
portant and  its  future  usefulness  is  now  so  well 
assured  that  we,  as  an  institution,  may  well  feel 
proud  that  our  efforts  have  been  so  steadfastly 
directed  toward  its  development.  The  general 
surgeon,  whose  ample  and  easily  obtained  train- 
ing fits  him  to  perform  the  cutting  operations 
for  the  relief  of  deformity,  finds  himself  fully 
occupied  in  keeping  abreast  with  the  current 
surgical  thought  and  literature  of  the  day.  The 
dexterous  operator  finds  his  time  fully  taken  up 
in  his  peculiar  and  special  work.  But  there  is 
another  side  to  surgery.  The  joint,  for  exam- 
ple, that  is  excised  in  many  instances  may  be 
saved;   the  limb  condemned  to  amputation  on 


THE   RELATION   TO   GENERAL   SURGERY.     49 

account  of  its  deformity  may  in  many  cases  be 
straightened.  Properly  applied  mechanico-ther- 
apy  will  save  many  of  the  deformities  that  fall 
into  the  hands  of  the  operative  surgeon.  In- 
deed, many  of  the  deformities  that  were  for- 
merly almost  habitually  operated  upon  can  be 
relieved  or  cured  by  orthopaedic  measures  with- 
out operation.  But  if  a  patient  with  deformity 
reaches  a  point  where  orthopaedic  measures  are 
contraindicated,  or  useless,  or  where  a  surgical 
operation,  with  ordinary  surgical  dressings  only, 
is  necessary  to  remove  the  deformity,  he 
should  at  once  be  placed  under  the  care  of  the 
general  surgeon.  Orthopaedic  surgeons,  in 
short,  ought  to  limit  their  work  to  their  own 
department — in  which  there  is  enough  to  do 
and  enough  to  learn,  without  interfering  in  the 
slightest  degree  with  the  already  overcrowded 
ranks  of  the  general  surgeon. 

Orthopaedic  surgeons  have  until  recently 
been  placed  at  a  great  disadvantage.  The  early 
followers  of  true  orthopaedic  surgery — and  some 
of  them  are  alive  to-day — were  necessarily  self- 
educated  in  orthopaedic  methods  and  work. 
They  had  no  school  or  college ;  no  hospital  or 
dispensary  to  which  they  could  go  to  receive 
instruction  in  orthopaedic    surgery.     Equipped 


50  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

as  regularly  educated  men,  amply  prepared  to 
amputate  a  limb  or  excise  a  joint,  etc.,  they 
were  not  taught  even  the  simplest  rudiments 
of  mechanico-therapy.  They  might  have  been 
told  that  "  Smith's  clubfoot  shoe  is  the  best," 
or  that  "Jones's  knock-knee  instrument  is  su- 
perior to  Brown's " ;  but  of  the  mechanical 
principles  involved  they  were  taught  little  or 
nothing.  In  addition  to  this,  they  had  to  meet 
and  overcome  the  still  existing  opprobrium  that 
attaches  to  the  subject  of  mechanical  treatment. 
They  had  also  to  meet  the  criticism  that  "  Dr. 
X.  could  perhaps  apply  a  clubfoot  shoe  pretty 
well,  but  he  could  not  amputate  a  limb  as  well 
as  Dr.  Y." — as  if  any  means  that  relieves  human 
suffering  is  beneath  the  dignity  of  the  most 
highly  educated  and  accomplished  surgeon  that 
ever  lived. 

This  is  becoming  changed.  There  are  sev- 
eral places  where  the  seeker  after  ortho- 
paedic knowledge  may  find  opportunities  for 
study ;  and  while  it  is  difficult  to  remove  the 
old  prejudice  that  exists,  especially  outside  of 
New  York  city,  it  will  not  be  long  before 
orthopaedic  surgery,  per  se,  will  occupy  its 
legitimate  place  in  the  estimation  of  the  entire 
medical   profession.       In   the  meantime,  ortho- 


THE  RELATION  TO  GENERAL  SURGERY. 


51 


pasdic  surgery  needs  men  who  will  work  and 
wait — men  who  will  patiently  investigate  the 
many  unsolved  questions  that  confront  it  on  all 
sides  ;  men  who  will  devote  themselves  to  a  true 
specialism,  and  who  will  steadfastly  refuse  to 
compete  with  the  general  surgeon  in  the  field  of 
operative  surgery. 

We  have  only  to  look  about  us  to  see  how 
fully  the  field  of  general  surgery  is  occupied. 
No  one  in  the  civilized  world,  requiring  the 
services  of  the  general  surgeon,  need  go  unre- 
lieved. The  general  hospitals  of  all  countries 
are  numerous  and  well-equipped,  and  this  is 
especially  true  of  our  own  great  city.  On  the 
other  hand,  what  are  the  special  provisions 
made  for  the  treatment  of  the  deformed? 
There  are  comparatively  few  surgeons  in  the 
whole  world  whose  early  education  and  train- 
ing fit  them  to  intelligently  apply  apparatus  to 
the  conditions  of  deformity.  In  some  of  the 
large  cities,  both  here  and  abroad,  there  are 
orthopaedic  dispensaries  and  hospitals,  but  the 
surgeons  connected  with  them  and  controlling 
them  are  too  frequently  men  with  strong  oper- 
ative instincts  and  training — surgeons  who  are 
accomplished  in  all  that  pertains  to  diagnosis, 
the  conventional  surgical  dressings  and  the  use 


52  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

of  the  knife,  but  who  are  necessarily  lacking 
in  the  special  training-  required  to  successfully 
apply  the  fundamental  principles  of  mechanico- 
therapy  to  an  average  case  of  progressive  de- 
formity. They  are,  by  nature  and  education, 
operative  surgeons  who  duly  recognize  the  value 
of  mechanico-therapy,  but  they  are,  I  think,  too 
often  willing  to  relegate  the  mechanical  detail  of 
treatment,  both  before  and  after  operation,  to  the 
uneducated  instrument-maker,  whose  interest  in 
the  patient  is  merely  a  commercial  one.  It  is 
largely  so  in  England,  France  and  Germany — it 
is  only  less  so  in  America.  At  the  same  time, 
there  are  quite  a  number  who  are,  strictly 
speaking,  orthopaedic  surgeons,  whose  educa- 
tion is  based  upon  an  early  and  prolonged  train- 
ing in  orthopaedic  methods,  and  it  is  to  these 
men  that  we  must  look,  I  think,  for  the  advance- 
ment of  true  orthopaedic  surgery. 

It  must  be  apparent  that  it  is  only  by  spe- 
cial effort  and  prolonged  study  and  work  that 
any  department  of  medicine  can  reach  its  maxi- 
mum of  benefit  to  the  human  race.  The  his- 
tory of  medicine  proves  that  many  of  its  great- 
est advances  have  been  made  by  broadly  edu- 
cated men  who  have  devoted  themselves  to 
special  branches  of  work.     And  so  it  is  in  ortho- 


THE  RELATION  TO  GENERAL  SURGERY.   53 

paedy.  It  is  not  the  surgeon  who  amputates  a 
thigh,  reduces  a  fracture  or  a  dislocation,  and 
applies  a  hip  splint  the  same  day,  that  is  likely 
to  advance  orthopaedic  science.  It  is  more 
likely  to  be  the  surgeon  who,  with  the  wide  and 
almost  unexplored  field  of  mechanico-therapy 
before  him,  devotes  his  life  to  demonstrating  its 
great  value  in  the  various  conditions  of  deform- 
ity and  deforming  diseases. 

The  function  of  the  orthopaedic  surgeon 
should  therefore  be  to  fill  a  place  not  occupied 
by  the  general  surgeon — to  do  a  work  that  the 
general  surgeon  is  either  unwilling  or  unfitted 
to  undertake,  and  to  aid  in  developing  an  im- 
portant department  of  surgery  which  has  been 
too  long  neglected  or  ignored.  Those  deform- 
ities which  general  surgery  is  competent  to 
relieve,  without  the  intervention  or  aid  of  the 
orthopaedist,  should  be  placed  at  once  under  the 
care  of  the  general  surgeon  ;  while,  on  the  other 
hand,  chronic  cases  requiring  special  mechani- 
cal treatment,  either  in  the  prevention  or  cure 
of  deformity,  should  be  placed  under  the  care 
of  the  orthopaedic  surgeon. 

It  is  my  experience  that  a  longer  training  is 
necessary  to  fit  one  to  be  an  orthopaedic  surgeon 
than  to  fit  one  to  be  an  operative  surgeon.     The 


54 


ESSAYS  ON   ORTHOPEDIC   SURGERY. 


brilliancy  of  operative  work  attracts  many  of 
the  best  men  in  the  profession,  while  the  hard 
and  rugged  work  of  mechanico-therapy  seems 
to  repel  many  who  are  adapted  to  orthopaedics ; 
and  yet  the  work  of  the  orthopaedist  may  be 
called  an  exact  science.  He  is  dealing  with 
mathematical  and  mechanical  problems  all  the 
time.  He  has  a  definite  object  in  view,  and  his 
therapy  is  controlled  by  his  own  hands.  He  is 
limited  in  the  application  of  his  principles  of 
treatment  only  by  the  vulnerability  of  the  hu- 
man tissues  ;  and  while  he  may  be  in  doubt  as  to 
the  best  "  method  "  to  be  employed,  he  is  never  in 
doubt  as  to  the  ultimate  principles  of  treatment. 
The  field  of  othopaedic  surgery  is  therefore 
a  very  wide  one — so  wide  and  so  comprehensive 
that  one  engaged  in  its  practice  need  not  en- 
croach on  the  field  of  the  general  surgeon. 
Still,  the  orthopaedic  surgeon  should  be  an  edu- 
cated operative  surgeon — and  he  should  be  pre- 
pared to  operate  upon  any  patient  who  requires 
special  mechcmical  treatment  after  operation.  But 
the  operative  treatment  should  be  secondary  to 
the  mechanical,  and  the  element  of  conservatism 
should  necessarily  enter  largely  into  the  work. 
The  patient  mechanical  work — may  be  of  years — 
necessary  to  save  a  limb  or  joint  from  deformity, 


THE  RELATION  TO  GENERAL  SURGERY.   55 

may  be  less  brilliant  than  the  operative  means 
that  removes  them,  but  the  real  merit  lies  in  that 
method  which  saves  the  limb  and  restores  the  af- 
fected individual  to  society  with  a  useful  member. 

In  an  essay  read  before  the  International 
Medical  Congress  held  in  Berlin  in  August  last 
the  writer  raised  the  question,  "  What  is  Ortho- 
paedic Surgery?"  and  he  ventured  to  define 
it  as  follows  :  "  Orthopaedic  surgery  is  that  de- 
partment of  surgery  which  includes  the  preven- 
tion, the  mechanical  treatment  and  the  opera- 
tive treatment  of  chronic  or  progressive  de- 
formities, for  the  proper  treatment  of  which 
special  forms  of  apparatus  or  special  mechanical 
dressings  are  necessary." 

The  conclusion  formulated  in  this  definition 
is  based  upon  nearly  twenty-two  years  of  work 
in  your  institution — seventeen  years  spent  in 
the  orthopaedic  ward  of  St.  Luke's  Hospital, 
combined  with  an  early  training  of  five  years  in 
the  New  York  Hospital  for  the  Relief  of  the 
Ruptured  and  Crippled.  It  places  your  insti- 
tution on  record  as  being  the  first  to  formulate  a 
definite  plan  of  work,  which  separates  ortho- 
paedic from  general  surgery,  and  which  aims  to 
cover  a  definite  field  not  included  in  that  of 
the  general  hospitals  and  dispensaries. 


THE    PRESENT    NEEDS   AND    FUTURE 

DEMANDS   OF  ORTHOPAEDIC 

SURGERY.* 

Gentlemen  :  As  I  rise  to  address  you  this 
evening  the  new  hospital  building  approaches 
completion.  Recently  remodeled  and  much  en- 
larged, it  is  fully  equipped  in  every  important 
respect  for  modern  orthopaedic  work. 

A  year  ago  we  were  deeply  in  debt.  The 
ordinary  dwelling  house  adjoining  your  prop- 
erty on  the  east,  unfitted  for  hospital  use,  had 
been  purchased.  We  were  without  means  to 
erect  a  suitable  hospital  structure  in  its  place. 
To-day,  through  the  kindness  of  friends,  a  new 
fireproof  hospital  building,  as  yet   not  wholly 


*  A  portion  of  an  address  delivered  before  the  trustees  of 
the  New  York  Orthopaedic  Dispensary  and  Hospital  upon  the 
occasion  of  its  twenty-ninth  annual  meeting,  held  November  16, 
1896. 

Reprinted  from  the  New  York  Medical  Journal  for  December 
12,  1896. 

56 


PRESENT  NEEDS  OF  ORTHOPEDIC  SURGERY.      57 

paid    for,  stands   in   the  place  of  the  property 
which  we  purchased.     Aided  by  this  additional 
building,  we  find  that  our  capacity  for  hospital 
patients  has  been  increased  one  third ;  we  have 
made  various    changes  in  the    Sloane   pavilion 
and  in  the  older  hospital  structure ;  an  elevator 
has    been    introduced ;    we    have    a    complete 
Rontgen-ray    apparatus,    a    modern    operating 
room  has  been    added    to   our  equipment,  and 
the  three  original  buildings  comprising  our  now 
consolidated  hospital  represent  all  that  the  most 
earnest  critic  could  demand  in  orthopedic  work. 
It  matters  but  little  where  the  examination  com- 
mences, whether  in  the  shop,  where  the  most  in- 
tricate and  delicate  apparatus  for  the  treatment 
of  deformity  can  be  made  ;   or  in  the  domestic 
department,  where    all    the    modern    improve- 
ments have  been  introduced,  the  progress  up- 
ward  from   story  to   story  develops   a  careful 
economy  of  space,  with  a  liberal   allotment  of 
room  for  both  the  dispensary  and  hospital. 

The  dispensary  is  especially  adapted  to  the 
needs  of  the  outdoor  patients,  who  crowd  the 
reception  and  treatment  rooms  daily.  It  is  on 
this  floor  that  the  X-ray  room  has  been  placed, 
and  it  is  here  also  that  the  interesting  work  of 
the  neurological  department  has  been  located. 


58  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

Nearly  the  whole  first  floor  of  the  three  build- 
ings comprising  our  remodeled  hospital  is  given 
up  to  dispensary  work. 

On  the  second  floor  are  located  the  rooms 
for  the  administrative  work  of  the  hospital,  the 
children's  dining  room,  and  the  operating  room 
— the  two  latter  being  rooms  that  would  attract 
attention  in  any  hospital. 

Six  wards,  accommodating  seventy-five  pa- 
tients, occupy  the  third  and  fourth  floors,  and 
everything  has  been  done  to  make  these  wards 
bright,  attractive,  and  aseptic,  while  the  prob- 
lem of  ventilation  has  received  its  full  share  of 
attention. 

The  fifth  story  contains  the  children's  play 
room,  the  roof  garden,  and  rooms  for  nurses, 
while,  at  a  remote  point  and  unconnected  with 
the  rest  of  the  house,  and  with  an  entrance 
from  an  open  roof  only,  there  is  an  isolated 
ward  with  suitable  sanitary  adjuncts,  for  sus- 
pected acute  infectious  and  contagious  dis- 
eases. 

This,  in  brief,  is  a  description  of  your  com- 
pleted building.  The  more  one  studies  the  ar- 
rangement of  the  various  parts  of  the  building 
and  notices  how  completely  the  compact  whole 
represents  the  needs  of  a  modern  and  progress- 


PRESENT  NEEDS  OF   ORTHOPEDIC    SURGERY.     59 

ive    orthopaedic  hospital,  the  more  the  friends 
of  your  work  must  be  satisfied. 

Modern  orthopaedic  work  demands  all  that 
you  have  given  your  medical  staff.  The  theo- 
ries of  a  few  years  ago  regarding  the  causation 
of  tuberculosis  have  become  demonstrated  facts. 
The  light  which  modern  bacteriological  investi- 
gation has  thrown  on  the  various  morbid  pro- 
cesses which  enter  into  the  question  of  the  pro- 
duction of  certain  chronic  deformities  is  no  less 
important  to  the  orthopaedic  than  to  the  general 
surgeon.  In  treating  these  deformities  from  the 
operative  standpoint,  the  orthopaedic  surgeon 
needs  the  same  training  as  the  general  surgeon, 
and  the  same  aseptic  and  general  surgical  care 
should  be  exercised,  for  example,  in  opening  a 
simple  abscess  connected  with  a  diseased  joint 
as  in  operating  for  an  acute  appendicitis.  But 
while  the  general  surgeon  covers  a  wide  opera- 
tive field,  the  orthopaedic  surgeon  finds,  in  his 
work,  a  more  limited  operative  field.  The  lat- 
ter, however,  should  be  no  less  a  surgeon  be- 
cause he  operates  in  those  cases  only  which 
require  special  orthopaedic  care  after  operation. 
To  extend  the  operative  field  of  orthopaedy  be- 
yond this  point  is  to  break  down  the  only  bar- 
rier between  it  and  general  surgery,  and  the 


6o  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

effect  is  to  belittle  true  orthopaedic  surgery 
and  to  emphasize  the  impression,  only  too  pro- 
nounced, that  the  tendency  of  the  orthopaedic 
surgeons  of  to-day  is  to  make  orthopaedy  a 
stepping  stone  to  general  surgery.  The  effect 
of  this  on  legitimate  orthopaedic  surgery  can  be 
imagined.  If  it  should  so  happen  that  the  pres- 
ent views  of  some  of  those  who  are  known  as 
orthopsedic  surgeons  should  prevail,  there  will 
be  no  orthopaedic  surgery,  except  as  it  may 
exist  as  an  adjunct  to  general  surgical  practice, 
and  the  real  foundation  of  orthopaedy — that  is, 
the  study  of  mechanico-therapy — will  be  rele- 
gated to  the  instrument-makers  from  whom 
legitimate  orthopaedic  surgery  rescued  it  not 
many  years  ago. 

Your  institution  stands  as  the  exponent  of 
legitimate  orthopaedic  practice.  Until  recently 
it  has  been  hampered,  by  the  lack  of  proper 
facilities,  in  the  full  performance  of  its  work. 
During  this  time  it  has  striven  patiently  and 
persistently  to  develop  the  much-neglected  side 
of  deformity  surgery — namely,  the  unattractive 
mechanical  side.  But  unattractive  as  is  this 
part  of  the  work  to  the  average  orthopaedic  or 
general  surgeon,  it  is  the  important  side,  and  it 
is  the  side  of  the  work  upon  which  the  success 


PRESENT   NEEDS  OF  ORTHOPEDIC  SURGERY.      6 1 

of  the  treatment  of  a  case  of  deformity  depends. 
It  seems  almost  useless  for  me  to  say  that  the 
same  attention  will  be  given  to  this  part  of  the 
work  in  your  institution  in  the  future  as  long-  as 
I  have  the  honor  of  being  its  surgeon-in-chief, 
and  I  dare  to  hope  that  my  successor,  whoever 
he  may  be,  will  hold  the  same  views.  The  addi- 
tion of  an  operating  room  simply  enables  us  to 
treat  our  patients  from  both  an  operative  and 
mechanical  standpoint.  It  does  not  mean  that 
the  operative  side  will  be  developed  at  the  ex- 
pense of  the  mechanical  work.  It  does  not 
mean  that  there  is  any  danger  of  your  hospital 
being  known  as  a  general  hospital,  where  all.  or 
even  many,  of  the  operations  of  surgery  are  to 
be  performed.  If  it  becomes  necessary  for  us  to 
operate  to  overcome  a  deformity,  and  the  pa- 
tient requires  special  orthopaedic  care  after 
operation,  we  propose  to  operate,  but  all  other 
patients  requiring  surgical  care  will  be  referred 
to  some  general  hospital,  where  they  belong. 

The  future  of  orthopaedic  surgery  depends 
upon  the  deliberate  study  and  development  of 
the  mechanical  aspect  of  the  work.  There  will 
always  be  operative  surgeons  who  can  perform 
the  cutting  operations  which  are  sometimes 
necessary  to  relieve  chronic  deformity.     On  the 


62  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

other  hand,  there  is  to-day  a  scarcity  of  surgeons 
who  understand,  or  who  have  been  taught  to 
apply,  the  principles  underlying  the  mechanical 
correction  of  deformity.  The  student  of  me- 
chanico-therapy  needs  encouragement,  and  the 
medical  profession  should  understand  more  fully 
that  it  is  only  by  a  conscientious  and  prolonged 
study  of  both  the  operative  and  mechanical  work 
that  a  fully  equipped  orthopsedic  surgeon  can 
be  produced.  It  is  taken  for  granted  even  in 
our  best  medical  colleges  that  a  student  is  a 
natural  mechanician — born  to  devise  and  apply 
apparatus  in  the  treatment  of  chronic  deformity 
— and  yet  I  venture  to  say  that  there  is  no  more 
delicate  or  difficult  problem  in  the  whole  field 
of  surgery. 

Who  will  be  the  first  one  to  endow  a  chair 
of  mechanico-therapy,  associated  with  a  clinical 
professorship  of  orthopaedic  surgery,  in  one  of 
our  medical  schools  ? 

To  apply  an  apparatus,  already  made,  to  a 
patient,  to  give  a  description  of  Smith's  hip 
splint,  or  Jones's  spinal  brace,  or  Robinson's 
clubfoot  shoe,  or  to  apply  a  plaster-of-Paris 
splint  in  presence  of  a  class  of  students,  is  like 
giving  a  simple  verbal  description  of  the  quad- 
riceps extensor  femoris  muscle  to  one  who  has 


PRESENT   NEEDS  OF  ORTHOPAEDIC  SURGERY.      63 

never  dissected  a  human  body.  Actual  train- 
ing in  mechanical  work  is  as  necessary  to  a  suc- 
cessful student  of  orthopaedy  as  is  dissection  to 
an  anatomist,  or  as  clinical  study  and  laboratory 
work  are  to  the  successful  development  of  the 
well-trained  medical  man.  As  the  old  style  of 
giving  didactic  lectures  in  medical  schools  has 
given  way  to  more  practical  and  scientific 
methods  of  instruction,  so,  in  the  future,  the 
present  methods  of  teaching  orthopaedic  sur- 
gery will  be  re-enforced  by  practical  work  in 
the  mechanical  room.  The  perfunctory  applica- 
tion of  an  apparatus  before  a  class  will  give  way 
to  a  description  of  the  fundamental  principles 
underlying  the  mechanical,  anatomical,  and  sur- 
gical problems  involved.  The  student  will  then 
be  obliged  to  apply  these  principles  under  the 
instruction  of  the  professor — and  the  student 
will  thus  gain  a  real  knowledge  of  the  subject. 

When  one  sees,  in  the  various  instrument- 
makers'  shops,  the  many  crude  and  incorrectly 
constructed  instruments  for  the  treatment  of 
chronic  deformity  which  are,  literally,  like  sugar 
or  salt,  in  the  market,  one  can  realize  the  embar- 
rassment of  the  average  medical  man  in  his  ef- 
fort to  cope  with  the  treatment  of  a  patient  with 
a  chronic  or  progressive  deformity.     His  guide 


64  ESSAYS  ON   ORTHOPEDIC   SURGERY. 

is  the  profusely  illustrated  catalogue  of  some 
enterprising  instrument-maker.  His  knowledge 
— for  there  are  no  text-books  on  the  mechanico- 
therapy  of  orthopaedic  surgery — is  limited  and 
his  failures  are  many.  The  existing  works  on 
orthopaedic  surgery  do  not  satisfactorily  cover 
this  field.  Whose  is  the  fault?  It  lies  wholly 
with  those  who  teach,  and  it  will  be  thus  until 
the  subject  of  mechanico-therapy,  as  applied  to 
the  problems  involved  in  orthopaedic  surgery,  is 
made  an  obligatory  course  in  the  medical  col- 
leges. 

So  far  as  is  possible  this  work  has  been  done 
in  your  institution  in  the  annual  course  of  lec- 
tures which  have  been  given  under  your  au- 
spices for  the  past  twenty  years.  It  has  been 
further  amplified  by  throwing  open  the  doors  of 
the  institution  to  those  who  wish  to  study  the 
mechanical  principles  involved  in  the  treatment 
of  deformity,  and  many  have  availed  themselves 
of  this  privilege.  There  are  at  present  three  or 
four  surgeons  from  various  distant  cities  who 
are  following  the  work  of  the  dispensary  and 
hospital.  Our  work  in  this  direction  might 
easily  be  increased  if  it  were  more  generally 
known  that  we  always  welcome  those  who  wish 
to  study  our  work  and  methods. 


PRESENT  NEEDS  OF  ORTHOPEDIC  SURGERY.     65 

From  causes  entirely  beyond  our  control  the 
Morgan  operating  room  was  not  completed 
until  early  in  the  summer.  We  had  used  the 
room  only  once  when  orders  came  to  remove 
all  the  hospital  inmates  to  the  country,  in  an- 
ticipation of  the  extensive  changes  in  the 
building — which  have  since  been  made.  On 
this  account,  and  also  on  account  of  the  flying 
mortar  dust  arising  from  the  demolition  of  the 
old  building,  it  was  deemed  best  to  keep  the  op- 
erating room  closed  all  summer.  The  furniture, 
etc.,  which  was  removed,  has  been  replaced  and 
the  room  is  now  in  order  and  operative  work 
has  already  begun. 

It  is  due  to  the  generosity  of  one  of  our 
trustees  that  we  have  a  complete  Rontgen-ray 
apparatus  as  a  part  of  our  regular  dispensary 
and  hospital  work.  Its  use  opens  a  large  field 
for  scientific  work  and  study.  It  will  serve  to 
throw  much  light  on  that  which  has  hitherto 
been  obscure  and  difficult.  In  all  the  diseases 
and  deformities  of  the  major  articulations  and 
long  bones,  and  also  in  other  respects,  its  assist- 
ance in  forming  a  picture  of  the  conditions  will 
be  invaluable — and  the  entire  medical  staff  of 
the  Hospital  desire  to  thank  the  gentleman  who 
made  this  valuable  present  to  the  institution. 


THE   OPERATIVE  SIDE 
OF  ORTHOPAEDIC  SURGERY* 

Gentlemen  :  The  founders  of  the  New 
York  Orthopaedic  Dispensary  and  Hospital 
builded  better  than  they  knew  when,  thirty- 
one  years  ago,  they  met  and  organized  the 
work  which  calls  us  together  on  this  occasion. 

Thirty-one  years  ago  orthopaedic  surgery 
was  scarcely  more  than  a  name  in  New  York 
city.  It  may  almost  be  said  that  few  outside 
of  the  medical  profession  and  the  technically 
educated  classes  grasped  the  full  meaning  of 
the  word  "orthopaedic."  A  few  surgeons,  in- 
spired largely  by  the  late  Dr.  Henry  G.  Davis, 
were  devoting  themselves  to  the  treatment  of 
deformities,  especially  those  occasioned  by  dis- 
eases of  the  spine  and  hip  joint.     Modern  ortho- 


*  A  portion  of  an  address  delivered  before  the  trustees  of  the 
New  York  Orthopaedic  Dispensary  and  Hospital  on  the  occasion 
of  its  thirtieth  annual  meeting,  held  November  15,  1897. 

Reprinted  from  the  Medical  Record,  December  18,  1897. 
66 


OPERATIVE  SIDE  OF  ORTHOPEDIC  SURGERY,      ty 

pasdic  surgery  was  in  its  infancy,  and  the  work 
of  these  pioneers  was  attracting  the  attention  of 
the  lay  as  well  as  the  professional  public.  It 
was  during  this  embryonic  period  that  the 
founders  of  your  institution  applied  to  the  State 
Legislature  for  a  charter,  in  the  following  lan- 
guage :  "  The  purposes  of  the  said  corporation 
shall  be  to  establish  and  maintain  an  institution 
for  the  treatment  of  physical  deformities  and  to 
give  instruction  in  such  treatment — and  more 
especially  to  afford  surgical  and  mechanical 
treatment  to  the  disabled  and  deformed  among 
the  poor." 

It  was  the  mechanical  genius  of  Davis  which 
contributed  greatly  to  this  new  era  in  the  treat- 
ment of  physical  deformities.  It  was  he  and 
his  colleagues  who  made  American  orthopaedic 
surgery  famous.  It  was,  however,  the  mechan- 
ical rather  than  the  surgical  side  of  orthopae- 
dy of  those  days  which  brought  to  the  front 
the  names  of  those  who  are  to-day  recognized 
as  the  fathers  of  orthopaedy  in  this  country,  and 
it  was  the  mechanical  treatment  of  hip-joint  dis- 
ease and  spinal  disease,  as  taught  by  Taylor, 
which  led  to  the  foundation  of  your  institution 
and  which  has  had  more  or  less  effect  upon  the 
development  of  American  orthopaedic  surgery. 


6%  ESSAYS  ON  ORTHOPEDIC  SURGERY. 

It  was  under  these  circumstances  that  your  spe- 
cial charter  was  obtained  from  the  New  York 
State  Legislature.  It  would  have  been  a  mat- 
ter of  no  surprise  to  me,  knowing  as  I  do  the 
sentiment  of  the  profession  in  those  early  days, 
and  appreciating  also  the  influences  which  origi- 
nated our  great  work,  if  the  charter  had  sim- 
ply designated  the  mechanical  treatment  of 
deformity  as  the  sole  object  of  the  corporation. 
But  with  a  wise  and  almost  prophetic  fore- 
sight, the  charter  was  framed  in  a'  broad  and 
liberal  sense,  and  the  portion  quoted  above 
might  almost  be  called  a  definition  of  modern 
orthopaedic  surgery. 

On  previous  occasions  I  have  called  your 
attention  to  the  relation  of  orthopaedic  surgery 
to  general  surgery — to  the  necessity  of  a  thor- 
ough mechanical  training  as  a  preparation  for 
orthopaedic  work,  and  to  the  future  demands  of 
orthopaedic  surgery  from  a  mechanical  stand- 
point. It  would  seem  only  proper  on  this  oc- 
casion, therefore,  that  I  should  dwell  somewhat 
upon  the  operative  aspect  of  the  treatment  of 
deformities. 

The  treatment  of  chronic  deformities  would 
be  emasculated  if  mechanical  treatment  was 
omitted.     Indeed,   under   those    circumstances, 


OPERATIVE  SIDE  OF  ORTHOPAEDIC  SURGERY.      69 

there  would  be  only  operative  surgery  left. 
On*the  other  hand,  if  operative  surgery  was 
omitted,  mechanico-therapy  would  still  find  an 
important  place  in  surgical  science  and  the 
major  part  of  orthopaedic  work  would  still  go 
on.  To  the  legitimate  orthopaedic  surgeon,  , 
therefore,  operative  work  takes  a  secondary 
and  minor  position,  just  as  the  mechanical  part 
takes  by  far  the  more  important  place ;  and  in 
true  orthopaedic  surgery  operative  work,  per  se, 
has  no  real  status.  In  short,  if  orthopaedic  sur- 
gery is  to  maintain  its  position  among  the  spe- 
cialties in  medicine,  it  must  exist  upon  a  me- 
chanical foundation  and  its  disciples  must  be 
experts  in  the  use  of  apparatus.  At  the  same 
time  the  orthopaedic  surgeon  should  be  well 
prepared  to  operate  upon  those  patients  who 
require  special  mechanical  treatment  after  oper- 
ation. Hence  it  is  that  I  maintain  that  the  sim- 
ple excision  of  joints  is  not  within  the  field  of 
orthopaedic  work,  because  the  general  surgeons 
and  the  general  hospitals  are  fully  equipped  to 
do  this  work  and  are  glad  to  receive  and  care 
for  this  class  of  cases,  the  after-treatment  of 
which  ordinarily  requires  no  special  orthopaedic 
training.  The  same  may  be  said  in  a  general 
way  of  the  operative  treatment  of  knock-knee 


;o 


ESSAYS  ON   ORTHOPAEDIC   SURGERY. 


and  bowlegs.  The  artificial  fracture  of  a  bone 
requires  the  same  treatment  as  an  accidental 
fracture,  and  this  certainly  comes  within  the 
scope  of  general  surgery.  Under  these  circum- 
stances there  is  no  occasion  to  fill  the  wards  of 
an  orthopaedic  hospital  with  patients  of  this 
class,  as  long,  at  least,  as  there  is  such  a  great 
demand  upon  it  for  strictly  orthopaedic  cases, 
which  are  not  as  a  rule  received  by  the  general 
hospitals.  For  example,  a  patient  with  knee- 
joint  disease  or  hip-joint  disease  needing  exci- 
sion, or  a  patient  with  rhachitic  leg  deformity 
requiring  osteotomy,  applies  for  admission  to 
your  wards.  Am  I,  as  your  surgeon-in-chief, 
justified  in  receiving  the  case  when  there  are 
fifty  or  more  cases  of  hip-joint  disease,  spinal 
disease,  clubfoot,  etc.,  which  urgently  demand 
your  care  and  which  are  awaiting  admission  to 
your  wards?  My  reply  is,  "  No."  We  could 
fill  our  wards  with  operative  cases  in  a  month, 
the  larger  number  of  which  do  not  require 
orthopaedic  care  after  operation,  and  which  can 
be  cared  for  in  every  way  in  the  general  hos- 
pitals. I  certainly  feel  it  my  duty  to  decline 
them,  when  the  only  objects  I  would  have  in 
admitting  them  would  be  to  gratify  a  personal 
ambition  to  appear  as  an  operative  surgeon,  and 


OPERATIVE  SIDE  OF  ORTHOPEDIC  SURGERY.     j\ 

to  submit  for  your  consideration  at  the  end  of 
the  year  an  ample  table  of  "  operations  per- 
formed. "  Some  surgeons  best  known  as  ortho- 
paedic surgeons  are  wasting  their  time  on  work 
that  is  well  done  by  general  surgeons  and  well 
performed  in  general  hospitals.  These  men  are 
making  a  serious  error,  I  think,  and  are  retard- 
ing the  normal  growth  of  true  orthopaedic  sur- 
gery. Some  day  these  facts  will  be  appreci- 
ated. It  may  not  be  in  my  day,  but  sooner  or 
later  the  truth  will  prevail,  and  both  the  medi- 
cal profession  and  humanity  will  be  benefited. 
In  the  mean  time  I  shall  keep  on  in  the  course 
I  marked  out  twenty-four  years  ago,  when  at 
an  early  age  in  my  professional  career  I  had  the 
opportunity  to  gratify  my  surgical  ambition  in 
the  orthopaedic  wards  of  St.  Luke's  Hospital. 
Nor  is  that  opportunity  lacking  now,  with  the 
great  mass  of  clinical  material  which  presents 
in  the  service  of  your  institution.  I  am 
gratified  to  know  that  the  seed  sown  near- 
ly a  quarter  of  a  century  ago  is  bearing  good 
fruit. 

The  operative  part  of  orthopaedic  surgery 
therefore  becomes  the  simple  but  necessary  ad- 
junct of  the  mechanical  work.  One  may  be  an 
operative  surgeon  and  know  but  little  or  noth- 


72 


ESSAYS   ON    ORTHOPEDIC   SURGERY. 


ing  of  real  orthopaedic  work,  but  the  ortho- 
paedist must  be  the  one  and  know  the  other. 
One  may  perform  all  the  major  operations  of 
surgery,  and  yet  not  have  the  requisite  techni- 
cal knowledge  properly  to  adjust  a  hip  splint 
or  a  spinal  brace.  The  orthopaedic  surgeon 
should  be  able,  if  the  after-treatment  demands 
it,  to  excise  a  joint  or  to  perform  any  operation 
which  supplements  mechanico-therapy,  but  in 
all  but  very  exceptional  cases  he  should  confine 
his  cutting  work  to  that  field  which  supple- 
ments his  mechanical  operations. 

Nor  does  it  follow,  I  think,  because  a  de- 
formity exists,  that  the  patient  should  neces- 
sarily come  under  the  care  of  the  orthopaedic 
surgeon,  any  more  than  that  the  general  con- 
dition giving  rise  to  the  retinitis  of  Bright's 
disease,  or  to  the  tabetic  atrophy  of  the  optic 
nerve  in  locomotor  ataxia,  should  come  under 
the  care  of  the  ophthalmologist.  All  special- 
ties have  their  origin  in  general  medicine  or 
general  surgery.  The  existence  of  a  specialty 
depends  upon  several  factors,  the  important 
one  being  the  necessity  for  the  development 
upon  certain  lines  of  a  neglected  branch  of 
medicine  or  surgery  involving  patient  study 
and  careful  research.     It  is  along  these   lines 


OPERATIVE  SIDE  OF  ORTHOPAEDIC  SURGERY.     73 

that  a  specialty  succeeds,  and  the  danger  of 
specialism  of  the  present  day  lies  in  the  fact 
that  those  who  follow  it  are  prone  to  invade 
other  fields.  The  fault  with  many  of  those  who 
are  known  best  as  orthopaedic  surgeons  is  that 
they  do  not  confine  themselves  to  orthopaedic 
work ;  they  often  operate  when  there  is  no  ne- 
cessity for  cutting,  and  they  are  not  familiar 
enough  with  the  technique  of  mechanical  work 
to  get  the  best  results  from  mechanico-therapy. 
They  do  the  work  of  the  general  surgeon  in- 
stead, neglecting  or  ignoring  the  plain  path  of 
duty  which  lies  so  patent  before  them. 

Why  is  this  so  ?  A  few  extracts  from  a  re- 
cent editorial  in  the  New  York  Medical  Record 
may  help  us  in  answering  this  question.  The 
editorial  referred  to  is  entitled,  "  Is  Gynaecology 
Destined  to  Become  an  Obsolete  Specialty?" 
After  a  general  consideration  of  the  relation  of 
gynaecology  to  general  surgery,  the  writer  says : 
"  Not  content  with  confining  themselves  to  their 
proper  region,  they  [the  gynaecologists]  have 
reasoned  that  their  familiarity  with  abdominal 
surgery  should  render  them  the  equals  if  not 
the  superiors  of  general  surgeons  in  the  han- 
dling of  cases  which  bear  no  relation  to  diseases 
of  the  pelvic  organs."     The  writer  then  asks: 


74  ESSAYS   ON   ORTHOPEDIC   SURGERY. 

"  How  is  it  that  this  change  has  come  about  in 
America,  when  abroad  the  distinction  between 
the  gynaecologist  and  general  surgeon  is  just  as 
sharp  as  ever?  It  appears  to  be  due  to  some 
extent  to  the  fact  that  the  commercial  factor  has 
become  prominent  to  the  exclusion  of  the  scien- 
tific." Again:  "  If  gynaecology  is  to  remain  a 
specialty,  it  must  be  because  its  followers  con- 
tinue to  demonstrate  the  fact  that  they  can  do 
the  work  better  than  the  general  surgeon.  .  .  . 
It  is  along  the  line  of  conservatism  that  the 
battle  must  be  fought,  not  radicalism."  Still 
further :  "  Gynaecology  is  the  natural  outgrowth 
of  general  surgery,  but  the  contrary  is  far  from 
being  true,  and  any  attempt  to  reverse  the 
condition  must  end  in  ultimate  failure."  And 
finally :  "  Let  gynaecologists  prove  that  their 
specialty  is  capable  of  development  along  other 
lines  besides  those  of  radical  surgery,  and  there 
is  no  danger  that  it  will  ever  come  to  be  re- 
garded as  unnecessary."  Comment  on  these 
plain  statements  seems  superfluous.  But  if  the 
words  "  orthopaedic  surgeon  "  or  "  orthopaedic 
surgery"  be  inserted  in  place  of  "gynaecologist" 
or  "  gynaecology,"  in  the  quotations  given  above, 
the  truth  will  be  apparent  to  the  candid  ob- 
server.    It  will  be  along  the  lines  of  conserva- 


OPERATIVE  SIDE  OF  ORTHOPEDIC  SURGERY.     75 

tism  that  orthopaedic  surgery  will  be  developed 
— not  on  the  lines  of  operative  surgery — and  it 
will  be  all  the  better  for  the  men  now  engaged 
in  preparing  for  future  work  in  orthopaedic 
surgery  if  they  bear  these  facts  in  mind. 


IS  ORTHOPEDIC  SURGERY  TO  BE- 
COME AN  OBSOLETE  SPECIALTY?— 
WITH   REMARKS   ON   SPECIALISM. 

To  the  Editor  of  the  Medical  Record  : 

Sir:  No  one  interested  in  the  advancement 
of  true  specialism  in  medicine  can  fail  to  thank 
you  for  your  editorial,  "  Is  Gynaecology  Des- 
tined to  Become  an  Obsolete  Specialty?" 
which  appeared  in  the  Medical  Record  of  Feb- 
ruary 27,  1897. 

Aside  from  the  merits  of  the  question  raised 
by  the  discussion  between  the  surgeons  and  the 
gynaecologists,  the  more  important  issue  is,  Is  it 
the  best  policy,  both  from  a  scientific  medical, 
and  humanitarian  standpoint,  for  any  special 
department  of  medicine  to  "  overlap "  and  in- 
vade other  fields?  All  will  admit  that  this  is  in 
many  instances  a  necessity  as  a  matter  of  study 
and  education.     But  as  a  matter  of  practice  it 

would  seem  to  be  an  error.     In  a  humble  way  I 

76 


IS   IT   AN   OBSOLETE   SPECIALTY?  77 

have  discussed  this  subject  elsewhere  when  my 
essay,  "  What  is  Orthopaedic  Surgery  ? "  was 
criticised  in  the  New  York  Medical  Journal  of 
November  7,  1891.  In  my  reply  *  I  say  :  "  It  is 
universally  admitted,  I  think,  that  all  specialists 
in  medicine  should  be  thoroughly  equipped 
both  in  medicine  and  surgery,  and  there  is  no 
reason  why  one  thus  equipped  should  not  prac- 
tice both  general  medicine  and  surgery.  It 
must,  however,  be  apparent  that  the  so-called 
specialist  who  does  this  weakens  his  own  claim 
to  specialism  and  apologizes  for  his  specialty. 
This  will  be  true  so  long  as  medicine  and  sur- 
gery, generally  speaking,  are  progressive,  and 
so  long  as  there  are  unsolved  truths  await- 
ing the  special  investigator  and  the  special 
student." 

Have  the  specialists  solved  all  the  truths  in 
their  special  departments?  How  many  have 
ceased  to  be  special  investigators  as  well  as  spe- 
cial practitioners  ? 

Unless  these  questions  can  be  satisfactorily 
answered  it  would  seem  that  the  reply  made 
to  my  critic  regarding  orthopaedic  surgery  is 
also  applicable  to  other  specialties. 

*  "  On  the  Definition  and  Scope  of  Orthopaedic  Surgery,"  New 
York  Medical  Journal,  November  14,  1891. 


jS  ESSAYS  ON   ORTHOPEDIC  SURGERY. 

I  do  not  stop  to  question  the  motives  of 
those  who  "  overlap."  They  may  be  honest  but 
mistaken,  or  they  may  be  selfish  or  "  commer- 
cial." But  it  is  a  fact  that  the  effect  of  the  pres- 
ent state  of  affairs  upon  the  entire  medical  pro- 
fession is  bad,  and  I  have  noticed  that  the  lay 
public  is  beginning  to  ask :  "  What  sort  of  a 
specialist  is  he  who,  in  his  office,  in  his  writ- 
ings, and  in  his  college  and  hospital  work  is  a 
specialist,  but  who  is  a  family  physician  and  a 
general  practitioner  among  a  selected  clientele 
on  other  occasions?" 

The  outlook  for  the  general  practitioner  is 
indeed  an  uncertain  one  if  the  "  specialist  "  is  to 
invade  the  domain  of  the  family  physician. 
Why  should  he  do  so? 

Not  long  ago,  for  example,  T  had  occasion  to 
send  a  gentleman  who  consulted  me  to  a  well- 
known  specialist.  With  my  full  approval  this 
specialist  took  entire  charge  of  the  conduct  of 
the  case.  He  is  now  duly  installed  as  the  regu- 
lar medical  attendant  of  not  only  the  patient 
himself,  but  of  his  immediate  family  and  some 
of  his  friends.  I  frankly  told  the  "specialist" 
that  I  was  surprised  at  his  course,  but  he  only 
smiled  and  said,  "  Others  do  it." 

This  is  no  excuse.     As  I  have  often  said  to 


IS  IT  AN   OBSOLETE  SPECIALTY?  79 

those  who  have  honored  me  by  asking  my  ad- 
vice regarding  the  adoption  of  a  specialty: 
"  One  can  make  no  better  investment  of  one's 
time  after  a  thorough  training  than  gradually 
to  adopt  a  specialty  when  opportunity  or  incli- 
nation favors.  When,  however,  a  certain  point 
is  passed,  or  a  hospital  or  college  position,  pre- 
senting an  opportunity  for  clinical  study  and 
investigation,  enables  one  to  assume  a  position 
as  an  authority,  one  should,  if  he  adopts  a  spe- 
cialty, cease  to  be  a  general  practitioner." 

The  demoralization  which  has  apparently  in- 
vaded the  gynaecological  field  has  already  left 
its  marks  on  orthopaedic  surgery,  and  the  re- 
marks made  in  your  editorial,  with  a  slight 
change  of  words,  are  applicable  to  quite  a  num- 
ber of  men  who  are  best  known  as  orthopaedic 
surgeons.  Not  content  with  a  patient  study  in 
the  wide  and  practically  unexplored  field  before 
them,  these  "  orthopaedic  surgeons  "  "  overlap  " 
and,  neglecting  legitimate  orthopaedic  work,  in- 
vade the  field  of  the  general  surgeon. 

There  are  orthopaedic  surgeons  to  whom 
even  laparotomy  is  not  a  stranger.  A  consider- 
able portion  of  a  chapter  in  a  recent  work  on 
orthopaedic  surgery  is  devoted  to  "  amputation 
at   the   hip  joint."     A   paper    read    before   the 


80  ESSAYS  ON   ORTHOPEDIC   SURGERY. 

American    Orthopaedic    Association   and    pub- 
lished in  its  Transactions  is  entitled  "Amputa- 
tion  as   an    Orthopaedic  Measure."     One  man, 
until  quite  recently  a  member  of  the  Orthopae- 
dic Association,  resigned  because  he  felt  that  he 
could  not  afford  to  have  it  known  that  he  was 
connected    with   the  association.      Other  good 
and  able  men,  starting  out  with  the  intent  and 
desire  of  becoming  orthopaedic  surgeons,  have 
failed   to   have   the  "  courage   of   their   convic- 
tions" at  a  critical  moment  and  have  become  in 
effect   general   surgeons.      And   the   profession 
smiles  and  the  communities  in  which  they  live 
can  not  see  any  great  difference   between   the 
general  surgeon  and  his  orthopaedic  competitor. 
Orthopaedic  surgery  is  bound  to   become  a 
great  specialty,  but  it  will  not  succeed  on  gen- 
eral surgical  lines.     Before  it  can  be  a  real  spe- 
cialty it  must  cease  to  appear  in  the  role  of  a 
competitor  with  general  surgery.     It  must  not 
"  overlap."     Its  disciples  must  cease  to  antago- 
nize the  best  elements  of  the  profession  by  pos- 
ing as  orthopaedists,  when  they  only  lack  op- 
portunity  to   become   general   surgeons.     And 
until  this  change  is  brought  about  there  will  be 
no  true  orthopaedic  surgery,  except  as  here  and 
there  a  man  stands  up  for  the  right  and  defies 


IS    IT   AN   OBSOLETE    SPECIALTY?  8 1 

criticism,  for  it  is  getting  to  be  almost  as  rare 
to  find  a  legitimate  orthopaedic  surgeon  as  it  is 
to  meet  with  an  orthodox  gynaecologist  who 
does  not  "  overlap  "  and  compete  with  the  gen- 
eral surgeon  in  operating  for  appendicitis,  etc. 

Many  do  not,  I  think,  appreciate  how  much 
there  is  in  orthopaedic  surgery,  outside  of  its 
somewhat  limited  operative  work,  or  how  far  it 
may  be  made  useful  to  humanity.  It  certainly 
can  not  aid  the  orthopaedist  to  compete  with  the 
general  surgeon,  and  indeed  there  is  no  neces- 
sity for  it.  If  it  were  accepted  and  understood 
by  the  profession  at  large  that  the  orthopaedic 
surgeon  should  confine  his  operative  work  to 
those  cases  which  require  special  orthopaedic 
care  after  operation,  the  entire  profession  would 
be  benefited ;  orthopaedic  surgery  would  find 
itself  busy  with  congenial  work,  and  it  would 
occupy  a  well-defined  and  enviable  position 
among  the  specialties. 

Newton  M.  Shaffer,  M.  D. 

28  East  Thirty-Eighth  Street,  New  York, 
March  10,  i8g^. 


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Brief  essays  on  orthopaedic  surgery 


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